Immediate Free Flap Reconstruction of Locally …



Immediate Free Flap Reconstruction of Locally Advanced Breast Cancer: Is It Safe?

Christopher A. Crisera, MD, Babak J. Mehrara, MD, James P. Watson, MD, Andrew L. Da Lio, MD

Introduction: Numerous studies have demonstrated that immediate breast reconstruction (IBR) after mastectomy is associated with improvements in quality of life and body image (1-3). However, IBR of locally advanced breast cancer (LABC) remains controversial. Concerns about delays in postoperative adjuvant therapy due to wound complications or prolonged recovery, as well as a theoretical potential for increased incidence of local recurrences or delays in the diagnoses of local recurrences have been cited as reasons to delay reconstruction in these patients. The ability of the reconstructed breast to withstand postoperative radiation has been debated (4-8). The purpose of this study was to evaluate the safety of microsurgical IBR in patients with LABC in the largest retrospective series to date.

Methods: The records of 766 consecutive patients treated microsurgical breast reconstruction between 1992-2002 at UCLA Medical Center were reviewed. Patients with the diagnosis of stage IIB or worse breast cancer who were treated with mastectomy followed by IBR were identified and analyzed. Patient demographics, comorbid conditions, smoking history, history of preoperative chemotherapy or radiation, flap types, hospital stay, transfusion requirements, early and late postoperative complications, timing of postoperative chemotherapy and radiation treatment, secondary operations, local recurrences, distant metastases, and the effects of radiation on the reconstructed breasts were studied. A panel of three surgeons evaluated standard postoperative photographs taken at least 6 months after completion of radiation therapy. Each patient treated with postoperative radiation therapy had their reconstruction graded on a 4-point scale for flap shrinkage and distortion. A cosmetic score (4-point scale) was also assigned to radiated and non-radiated reconstructions for comparison.

Results: 170 patients with LABC who underwent microsurgical IBR were identified. There were 157 unilateral and 13 bilateral reconstructions (183 flaps). The free TRAM flap was used in the vast majority (162). The average age was 47 and 27.6% of patients had co-morbid conditions. The average hospital stay was 5.1 days, and 37 (21.8%) patients required banked blood transfusions. Fifty-seven patients (33.5%) had early postoperative complications. Fifteen patients (8.8%) had major postoperative complications of which 10 occurred in the early postoperative period (1 total flap loss (0.6%), 3 arterial/venous thromboses (1.8%), 2 partial flap losses (1.2%), and 4 hematomas requiring return to the operating room (2.4%)). Wound complications were noted in 39 patients (22.9%) and most commonly involved mild mastectomy flap necrosis (21 patients). Adjuvant postoperative therapy was delayed in 8 patients (4.7%), and the maximum delay was 3 weeks in one patient. There were no delays in the diagnosis of local recurrences that were attributable to the reconstruction. Fifty-six patients experienced late postoperative complications (32.9%). By far the most common late postoperative complication was fat necrosis, which occurred with an overall incidence of 24.6%. In the majority of these patients (24/45; 53.3%) fat necrosis was small ( ................
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