Fifteen percent of women treated for breast cancer with total mastectomy receive immediate or early breast reconstruction.1,2 The percentage is higher in young women and those treated in tertiary care medical centers. Immediate breast reconstruction (IBR) has several advantages.3,4 It can prevent some of the negative psychological and emotional sequelae seen with mastectomy. The aesthetic results of immediate reconstruction are superior to those seen after delayed reconstruction. IBR also reduces hospital costs by reducing the number of procedures and length of hospitalization. IBR has the potential to impact the treatment of breast cancer. It could affect the delivery of adjuvant therapy and the detection and treatment of recurrent disease. Chemotherapy and radiation therapy could also impact the complication rates of reconstruction. The oncologic considerations of breast reconstruction are outlined in this chapter.
Skin sparing mastectomy (SSM) has markedly improved the aesthetic results of IBR (Fig. 74-1). Preservation of the native skin envelope and the inframammary fold reduces the amount of tissue necessary for reconstruction.5 Breast symmetry can often be achieved without operating on the contralateral breast, and the periareolar incisions are inconspicuous in clothes.
A. Preoperative photograph. B. Postoperative photograph after skin-sparing mastectomy and transverse rectus abdominis musculocutaneous flap reconstruction.
There have been concerns that the skin and inframammary fold preservation reduce the effectiveness of total mastectomy. Despite these concerns, there is a large body of evidence that the local recurrences (LRs) after SSM are comparable to non-SSM.6-8 Care must be taken, however, in patients with superficial cancers or diffuse ductal carcinoma in situ (DCIS) to assure adequate surgical margins. The follow-up of patients after SSM to detect LRs is discussed in the next section.
The role of postreconstruction imaging after the treatment of breast cancer remains controversial. There is a paucity of data that addresses the issue and there no established guidelines.9 The incidence of LR of breast cancer is related to tumor stage. Most LRs after total mastectomy are in the skin and subcutaneous tissue and are readily detected by physical examination.10 A flap or implant could potentially delay the discovery of chest wall recurrences.
Systemic relapse is not inevitable following LR, especially after the treatment of DCIS.11,12 This argues that early detection of LRs may have a potential survival impact. All forms of mastectomy leave residual breast tissue. The differences are in terms of the microscopic breast tissue left behind in the skin and inframammary fold, which are largely preserved after SSM. Torresan et al evaluated residual glandular tissue in the skin flaps that would have been preserved after SSM.13 They found that 60% contained residual glandular tissue, and it correlated with skin flap thickness.