breast reconstruction: current strategies and future...

Hani Sbitany, MD

Assistant Professor of Surgery University of California, San Francisco

Division of Plastic and Reconstructive Surgery

Breast Reconstruction: Current

Strategies and Future

Opportunities

11th Annual School of Breast Oncology 2013

Atlanta, Georgia

November 8, 2013

Repair of Partial Mastectomy Defects

with Oncoplastic Surgery

SOBO 2012 Presentation

SOBO 2012 Presentation

Oncoplastic Reconstruction – Effects of

Timing on Complication Rates

All

Reconstruction

following Partial

Mastectomy

Immediate

Reconstruction

Before XRT

Delayed

Reconstruction

after XRT

30%

26%

42%

Kronowitz, SJ, et.al. Determining the optimal approach to breast reconstruction after partial

mastectomy. Plast Reconstr Surg. Jan. 2006.

Techniques for Oncoplastic Surgery

• Local Tissue Rearrangement • B to C cup breast •Small tumor •Grade 1 ptosis •No skin resection

• Oncoplastic Reduction Mammoplasty •C to D cup breast •Grade 2 to 3 ptosis •Some skin resection

Kronowitz, SJ, et.al. A Management Algorithm and Practical Oncoplastic Surgical Techniques to Repair Partial

Mastectomy Defects. PRS 2008.

Local Tissue Rearrangement

Kronowitz, SJ, et.al. A Management Algorithm and Practical Oncoplastic Surgical Techniques to Repair Partial

Mastectomy Defects. PRS 2008.

Local Tissue Rearrangement

Oncoplastic Reduction Mammoplasty

-Use of neoadjuvant

chemotherapy

-Breast conservation

therapy (BCT)

-Oncoplastic mammoplasty

-Extends BCT option

-Improved cosmetic results

-Minimizes adverse

effects of XRT

Indications

- Minimal Skin Resection or Tumor within Wise

Pattern

- C-Cup Breast Size with ptosis or Small Tumor

- D-Cup Breast size

SOBO 2012 Presentation

Kronowitz, SJ, et.al. A Management Algorithm and Practical Oncoplastic Surgical Techniques to

Repair Partial Mastectomy Defects. PRS 2008.

Locally advanced breast cancer

- Neoadjuvant chemotherapy

- Post-operative radiation therapy

Oncoplastic mammoplasty

(N = 37)

Mastectomy with immediate breast

reconstruction

(N = 64)

Two-stage TE

(N = 40)

Autologous (N = 24)

Review of prospectively-maintained surgical

outcomes database

Peled AW, Foster R, Sbitany H, Esserman L. Oncoplastic mammoplasty as a strategy for reducing reconstructive complications associated

with post-mastectomy radiation therapy. Presented at the 2013 American Society of Plastic Surgery Meeting, San Diego, California.

October 12, 2013.

Patients Oncoplastic mammoplasty

(N = 37)

Mastectomy/reconstruction

(N = 64)

Mean age 52.3 years 45.5 years

Mean BMI 29.2 kg/m2 25.2 kg/m2

Diabetes 2 (5.4%) 1 (1.6%)

Tobacco use 1 (2.7%) 0

Tumor stage

I 0 0

II 20 (54.1%) 29 (45.3%)

III 14 (37.8%) 33 (51.6%)

IV 3 (8.1%) 2 (3.1%)

Median follow-up 32 months (4 – 116) 30.5 months (8 – 74)

Peled AW, Foster R, Sbitany H, Esserman L. Oncoplastic mammoplasty as a strategy for reducing reconstructive complications associated

with post-mastectomy radiation therapy. Presented at the 2013 American Society of Plastic Surgery Meeting, San Diego, California.

October 12, 2013.

Oncologic Outcomes

Recurrence-free survival

Cancer-specific survival

Oncoplastic mammoplasty

Mastectomy/reconstruction

P = 0.29

P = 0.27

Oncoplastic mammoplasty

Mastectomy/reconstruction

Peled AW, Foster R, Sbitany H, Esserman L. Oncoplastic

mammoplasty as a strategy for reducing reconstructive

complications associated with post-mastectomy radiation

therapy. Presented at the 2013 American Society of Plastic

Surgery Meeting, San Diego, California. October 12, 2013.

0

10

20

30

40

50

Oncoplastic mammoplasty

Mastectomy/reconstruction

**

19%

45%

3%

38%

11%

30%

16%

36%

5% 8%

Complications

Peled AW, Foster R, Sbitany H, Esserman L. Oncoplastic mammoplasty as a strategy for reducing reconstructive complications associated

with post-mastectomy radiation therapy. Presented at the 2013 American Society of Plastic Surgery Meeting, San Diego, California.

October 12, 2013.

•Oncoplastic mammoplasty with equivalent oncologic safety

and fewer complications in setting of neoadjuvant chemo and

PMRT

•Early evaluation by plastic surgeon/multi-disciplinary

approach

•Role in pre-operative patient

counseling/decision-making

Conclusions – Oncoplastic

Reduction

Peled AW, Foster R, Sbitany H, Esserman L. Oncoplastic mammoplasty as a strategy for reducing reconstructive complications associated

with post-mastectomy radiation therapy. Presented at the 2013 American Society of Plastic Surgery Meeting, San Diego, California.

October 12, 2013.

Treatment Algorithm

Peled AW, Foster R, Sbitany H, Esserman L. Oncoplastic mammoplasty as a strategy for reducing reconstructive complications associated

with post-mastectomy radiation therapy. Presented at the 2013 American Society of Plastic Surgery Meeting, San Diego, California.

October 12, 2013.

Oncoplastic Reduction Mammoplasty

Breast Reconstruction

After Mastectomy

Immediate Reconstruction

Immediate Reconstruction

SOBO 2012 Presentation

Delayed Reconstruction

Implant-Based Breast

Reconstruction

• Two-Stage Implant

• One-Stage Implant

Two-Stage Breast Reconstruction

Tissue Expander Followed By Permanent Implant

Two-Stage Breast Reconstruction

Tissue Expander Followed By Permanent Implant

Two-Stage Implant Example of Outcome

Two-Stage Implant: 2nd Stage

Additional Enhancements

ADM: Acellular Dermal Matrices

Acellular Dermal Matrix

Autologous Fat Grafting

Microsurgical Breast

Reconstruction

TRAM/DIEP Flap Breast

Reconstruction

Pedicled TRAM Flap

Free (Microvascular)

TRAM Flap

Free & Pedicled TRAM Flap

ABDOMINAL DONOR SITE

VARIATIONS ON BLOOD SUPPLY TO

FLAP Muscle Sparing Free

TRAM Flap

DIEP: Deep Inferior Epigastric

Perforator Flap

GAP: Gluteal Artery Perforator

Perforator Flaps

Abdominal Wall Perforators

Abdominal Wall Perforators

Deep Inferior Epigastric Perforator

Deep Inferior Epigastric Perforator

(DIEP) Flaps

SOBO 2012 Presentation

Case Example: DIEP

Flap

SOBO 2012 Presentation

Redesigned GAP Flap

Kronowitz, SJ. The Gluteal Artery Perforator Flap Re-designed for Breast Reconstruction. PRS,

March 2008.

Case Example: Redesigned GAP flap

SOBO 2012 Presentation

Case Example: Redesigned GAP flap

SOBO 2012 Presentation

Total Skin Sparing Mastectomy

47

Sbitany H, Foster RD, et al. Outcomes Comparison of Techniques for Tissue Expander Coverage

Following Total Skin Sparing Mastectomy: A One-Year Institutional Experience. Submitted for

Publication.

UCSF Data, January 2012 – January 2013

Outcomes after total skin-sparing mastectomy

and immediate reconstruction: A 12-year

experience

Anne Warren Peled, MD

Frederick Wang, MD

Eric Wang, MD

Robert D. Foster, MD

Laura J. Esserman, MD, MBA

Hani Sbitany, MD

Total skin-sparing

mastectomy Preservation of entire breast

skin envelope with excision

of nipple-areolar complex

(NAC) tissue

Benefits

Aesthetic

Psychological

Purpose

Review 12-year experience with nipple-sparing mastectomy

(NSM) and immediate reconstruction

-Oncologic outcomes

-Surgical complications

Methods

Prospectively-maintained database of TSSM and

immediate reconstruction (2001-2012)

Outcomes

Tumor recurrence

-Local-regional

-NAC

Post-operative complications

-NAC necrosis

-Mastectomy skin flap necrosis

Tumor characteristics Total patients 599

Total cases 924

Indication for mastectomy

Therapeutic 604 (65.4%)

Prophylactic 320 (34.6%)

Contralateral 60%

Bilateral 40%

Tumor stage

In situ 148 (16%)

Stage I 204 (22.2%)

Stage II 162 (17.5%)

Stage III 84 (9.1%)

Stage IV 6 (0.6%)

Prophylactic 320 (34.6%)

Treatment characteristics

Chemotherapy

Any 294 (49%)

Neoadjuvant 195 (66%)

Adjuvant 99 (34%)

Radiation therapy

Any 181 (20%)

Prior history 67 (37%)

Post-mastectomy 114 (63%)

TSSM incisions

0%

20%

40%

60%

80%

100%

1st 100 cases Next 557 cases

IMF

Radial

Lateral

Mastopexy (< 30% of NAC)

Mastopexy (>30% of NAC)

Free graft

NAC crossing

Inframammary Radial Lateral/

Inferolateral

Mastopexy Type

Involving < 30% of the NAC

Preferred

Involving > 30% of the NAC

Circumareolar/ Free

Graft NAC

Crossing

No longer

recommended

Reconstructions performed

Two-stage

expander-implant Microvascular

(abdominal, gracilis)

Transverse rectus

abdominis myocutaneous

(TRAM) flap

Immediate

permanent implant

0%

20%

40%

60%

80%

100%

1st 100 cases Next 557 cases

Immediate implant

TRAM flap

Microvascular

2-stage expander-implant

Ischemic complications

(n=6) (n=5) (n=17) (n=24) (n=15) (n=46) (n=117) (n=143) (n=159) (n=125) (n=6) (n=5) (n=17) (n=24) (n=15) (n=46) (n=117) (n=143) (n=159) (n=125)

(n=6) (n=5) (n=17) (n=24) (n=15) (n=46) (n=117) (n=143) (n=159) (n=125) (n=6) (n=5) (n=17) (n=24) (n=15) (n=46) (n=117) (n=143) (n=159) (n=125)

0%

5%

10%

15%

20%

Nipple necrosis (partial or complete) Skin flap necrosis

1st 100 cases

Next 557 cases

Latest cohort

Local-regional recurrence N Local recurrence, n

(%)

All patients

(median follow-

up: 28 months)

Total

Invasive cancer

In situ cancer

412

301

111

8 (1.9)

5 (1.7)

3 (2.7)

Patients with

minimum 36

months follow-up

(median: 45

months)

Total

Invasive cancer

In situ cancer

126

95

31

3 (2.4)

2 (2.2)

1 (3.2)

No recurrences in the NAC

Distant recurrence

N Distant recurrence,

n (%)

All patients

(median follow-

up: 28 months)

Total

Invasive cancer

In situ cancer

412

301

111

12 (2.9)

11 (3.7)

1 (0.9)

Patients with

minimum 36

months follow-up

(median: 45

months)

Total

Invasive cancer

In situ cancer

126

95

31

2 (1.6)

2 (2.2)

0 (0)

Conclusions

Low rates of local-regional recurrence

No recurrences in the NAC

Low rates of ischemic complications

Targeted technical improvements

-Incisions avoiding NAC

-Minimal pressure on NSM skin flaps

--2-stage tissue expander reconstruction

--Delayed autologous reconstruction

Thank You