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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
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Repair of Partial Mastectomy Defects
with Oncoplastic Surgery
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SOBO 2012 Presentation
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SOBO 2012 Presentation
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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.
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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.
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Local Tissue Rearrangement
Kronowitz, SJ, et.al. A Management Algorithm and Practical Oncoplastic Surgical Techniques to Repair Partial
Mastectomy Defects. PRS 2008.
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Local Tissue Rearrangement
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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
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Kronowitz, SJ, et.al. A Management Algorithm and Practical Oncoplastic Surgical Techniques to
Repair Partial Mastectomy Defects. PRS 2008.
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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.
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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.
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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.
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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.
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•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.
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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.
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Oncoplastic Reduction Mammoplasty
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Breast Reconstruction
After Mastectomy
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Immediate Reconstruction
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Immediate Reconstruction
SOBO 2012 Presentation
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Delayed Reconstruction
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Implant-Based Breast
Reconstruction
• Two-Stage Implant
• One-Stage Implant
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Two-Stage Breast Reconstruction
Tissue Expander Followed By Permanent Implant
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Two-Stage Breast Reconstruction
Tissue Expander Followed By Permanent Implant
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Two-Stage Implant Example of Outcome
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Two-Stage Implant: 2nd Stage
Additional Enhancements
ADM: Acellular Dermal Matrices
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Acellular Dermal Matrix
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Autologous Fat Grafting
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Microsurgical Breast
Reconstruction
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TRAM/DIEP Flap Breast
Reconstruction
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Pedicled TRAM Flap
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Free (Microvascular)
TRAM Flap
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Free & Pedicled TRAM Flap
ABDOMINAL DONOR SITE
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VARIATIONS ON BLOOD SUPPLY TO
FLAP Muscle Sparing Free
TRAM Flap
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DIEP: Deep Inferior Epigastric
Perforator Flap
GAP: Gluteal Artery Perforator
Perforator Flaps
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Abdominal Wall Perforators
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Abdominal Wall Perforators
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Deep Inferior Epigastric Perforator
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Deep Inferior Epigastric Perforator
(DIEP) Flaps
SOBO 2012 Presentation
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Case Example: DIEP
Flap
SOBO 2012 Presentation
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Redesigned GAP Flap
Kronowitz, SJ. The Gluteal Artery Perforator Flap Re-designed for Breast Reconstruction. PRS,
March 2008.
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Case Example: Redesigned GAP flap
SOBO 2012 Presentation
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Case Example: Redesigned GAP flap
SOBO 2012 Presentation
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Total Skin Sparing Mastectomy
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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
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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
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Total skin-sparing
mastectomy Preservation of entire breast
skin envelope with excision
of nipple-areolar complex
(NAC) tissue
Benefits
Aesthetic
Psychological
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Purpose
Review 12-year experience with nipple-sparing mastectomy
(NSM) and immediate reconstruction
-Oncologic outcomes
-Surgical complications
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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
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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%)
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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%)
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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
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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
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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
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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
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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)
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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
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Thank You