Immediate Free Flap Reconstruction of Locally …



Immediate Free Flap Reconstruction of Locally Advanced Breast

Cancer: A 10-Year Review

Babak J. Mehrara, MD, Andrew Smith, MD, Eric Arcilla, MD, Timothy Santoro, MD, Jeffery Sebastian, MD, James P. Watson, MD, Andrew L. Da Lio, MD, and William W. Shaw, MD

Introduction

Immediate breast reconstruction (IBR) has many advantages over delayed reconstruction including improved cosmetic results, technical ease, lowered costs, and decreased overall recovery times.1, 2 In addition, numerous studies have demonstrated that breast reconstruction is an important coping mechanism and is associated with improvements in quality of life and body image. 3-8 Despite these benefits, 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 diagnosis of local recurrences have been cited as reasons to delay reconstruction in these patients. In addition, the ability of the reconstructed breast to withstand postoperative radiation has been questioned.9

The purpose of this study was to evaluate the safety and efficacy of microvascular autogenous IBR in women with LABC. In addition, we analyzed the effects of radiation therapy on the reconstructed breasts and evaluated patient satisfaction through telephone interviews.

Methods

A retrospective review of all patients who underwent microvascular breast reconstruction at UCLA Medical center from December 1991 to December 2002 was performed. All microvascular breast reconstructions were reviewed and patients with clinical stage IIB or worse breast cancer who were treated with mastectomy and IBR were identified. Patient demographics, early and late postoperative complications, local recurrences, distant metastases, and the effects of radiation on the reconstructed breast were studied. Multivariate logistic regression analysis was performed in an effort to identify potential risk factors for early and late postoperative complications. Telephone interviews were performed by physicians not involved in the original surgery and addressed overall satisfaction, cosmetic appearance, willingness to undergo immediate reconstruction again, willingness to recommend immediate reconstruction to a friend or colleague, and the effect, if any, of radiation on the reconstructed breast.

Results

Nine hundred and fourteen patients underwent microvascular breast reconstruction at UCLA Medical Center during the study period. Of these, 170 had locally advanced breast cancer. There were 157 unilateral and 13 bilateral reconstructions (183 reconstructions). The median age was 47 years and the median follow up was 24.0 months (range 1.4 to 142). Comorbid conditions were present in 26.5% of the patients. Patients with stage IIB cancer made up 35.9% of the total patient population, while 31.8% were stage IIIA, 22.5% stage IIIB, and 10.0% stage IV. TRAM flaps were used in most patients (149 patients). Radiation therapy was administered to 100 patients (28 preoperatively; 72 postoperatively) while 64 patients did not receive adjuvant radiation therapy.

Fifty-seven patients (33.5%) had early postoperative complications. Thirteen patients (7.6%) 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 were usually mild mastectomy flap necrosis (21 patients). Eight patients experienced a delay in the start of postoperative chemotherapy due to wound healing complications. The longest delay was 3 weeks. Forty-nine patients experienced late postoperative complications (28.8%). By far the most common late postoperative complication was fat necrosis, which occurred with an overall incidence of 26.5%. In the majority of patients (53.3%) fat necrosis was small or insignificant in size ( ................
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