Elsevier

Surgical Oncology

Volume 17, Issue 2, August 2008, Pages 97-105
Surgical Oncology

Review
Oncological safety and patient satisfaction with skin-sparing mastectomy and immediate breast reconstruction

https://doi.org/10.1016/j.suronc.2007.11.004Get rights and content

Summary

Introduction

The management of early breast cancer with skin-sparing mastectomy (SSM) and immediate breast reconstruction (IBR) is not based on evidence from randomised controlled trials. The purpose of this study is to evaluate the oncological safety, post-operative morbidity and patients’ satisfaction with SSM and IBR using the latissimus dorsi (LD) myocutaneous flap and/or breast prosthesis.

Methods

Eighty-three consecutive women underwent 93 SSMs with IBR (10 bilateral), using the LD flap plus implant (n=55) or implant alone (n=38), indications included early breast cancer and prophylaxis due to BRCA-1 gene mutation. Nipple reconstruction was performed in 38 patients, using the trefoil local flap technique, nipple sharing or Monocryl mesh. Twenty-three underwent contra-lateral surgery in order to optimise symmetry, including 15 augmentations and eight mastopexy/reduction mammoplasties. Patient satisfaction with the outcome of surgery was assessed on a linear visual analogue scale ranging from 0 (not satisfied) to 10 (most satisfied).

Results

There was no local recurrence (LR) after a median follow-up of 34 months (range=3–79 months). Overall survival was 98.8%, three patients developed distant disease and one patient died of metastatic breast cancer. No case of partial or total LD flap loss was observed. Morbidities included infection, requiring implant removal in two patients and one patient developed marginal ischaemia of the skin envelope. Significant capsule formation, requiring capsulotomy, was observed in 87% of patients who had either PMR or prior RT compared with 13% for those who did not have RT. Sixty-one (73.5%) of 83 patients completed the questionnaire with a median and mean satisfaction scores of 10.0 and 9.3, respectively (range=6–10).

Conclusion

SSM with IBR is associated with low morbidity, high levels of patient satisfaction and is oncologically adequate for Tis, T1 and T2 tumours without extensive skin involvement.

Section snippets

Introduction and background

The primary aim of surgical intervention in breast cancer is to achieve local control of disease. Secondarily, surgery to the breast and axilla provides material that can used to facilitate the planning of adjuvant local and systemic therapy. Over the last two decades a third objective has emerged, namely patient satisfaction, both with the process and end-result of surgical intervention. Historically, this has been seen as a competing interest, with the aspirations of the patient conflicting

Patients and methods

All procedures were performed by the same surgeon (K.M.), between 2001 and 2007, in one of three independent sector healthcare centres in London. The medical records of 83 consecutive women were reviewed. Each member of the case series underwent SSM and IBR and 10 patients had bilateral SSM and IBR (five had bilateral cancer, four had contra-lateral prophylactic surgery and one BRCA-1 gene carrier had bilateral prophylactic SSM and IBR). In total, there were 93 SSMs with IBR and the standard

Surgical considerations

We differentiated between two types of SSM: standard SSM where the whole skin envelope of the breast was preserved except for the NAC and NP-SSM where the whole skin envelope of the breast was preserved. The standard SSM was performed through a peri-areolar incision and the infra-mammary fold was preserved in all cases. The peri-areolar incision was adequate to remove all breast tissue in most cases. Patients with clinically negative axillae underwent sentinel node biopsy (SNB) using blue dye

Results

The median patients’ age was 47 years (range=27–72). Histological analysis of resection specimens showed pure DCIS in 15 patients and invasive carcinoma (+/− DCIS) in 72 patients. One patient carrying BRCA-1 gene mutation had bilateral prophylactic mastectomy with normal histology and another patient had a malignant phyllodes tumour. The histological findings in SSM specimens are shown in Table 1, classified according to the TNM system. The median tumour size was 28 mm (range 1–100 mm) and in all

Discussion

Despite numerous studies demonstrating the oncological adequacy of SSM and IBR, concerns still remain about the safety of this procedure, particularly with regard to LR within the preserved skin envelope. Ho et al. [4] performed histological examination of the 30 NSSM specimens and found the skin flaps (excluding the NAC) to be involved with cancerous cells in 23%. In two women, the skin involved was not directly over the tumour, implying spread via the dermal lymphatics. Overall, 12% of

Conclusion

SSM and IBR are oncologically safe in appropriately selected patients with Tis, T1 and T2 tumours in the absence of extensive skin involvement. Utility for higher stage tumours remains controversial. NAC preservation is possible for remote tumours, providing a frozen section protocol is followed. The technique is aesthetically superior to NSSM with delayed reconstruction and is associated with high levels of patient satisfaction and a low morbidity. Randomised controlled trials are required to

Conflict of Interest Statement

None.

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