Inservice Exam - 2005
Breast Reconstruction

A 60-year-old woman with breast cancer is scheduled to undergo modified radical mastectomy followed by postoperative radiation therapy. Which of the following techniques will yield the most natural appearance of the breast with the fewest complications?

(A) Delayed reconstruction with an autologous tissue flap
(B) Delayed reconstruction with a tissue expander followed by implantation of a prosthesis
(C) Immediate reconstruction with an autologous tissue flap
(D) Immediate reconstruction with a tissue expander followed by implantation of a prosthesis

The correct response is Option A.

Reconstruction of the breast with a delayed (nonradiated) autologous tissue flap will yield the best breast appearance if postmastectomy chest radiation therapy is needed.

Radiation therapy negatively affects reconstructive outcomes with implants, causing a marked increase in capsular contracture and other complications. These complications are unrelated to the type of implant.

Totally autologous reconstruction is the best option for reconstruction of a radiated breast. In implant reconstruction of a radiated breast, the latissimus flap can be used to salvage tissue with periprosthetic contractures, particularly in a patient who is not a good candidate for a TRAM flap. The final outcome is not as good as that obtained with autologous tissue alone but can be acceptable.

In one study, patients who had immediate reconstruction with a TRAM flap followed by radiation therapy were compared with patients who had radiation therapy followed by delayed reconstruction with a TRAM flap. The study found that the incidence of late complications was significantly higher in the immediate reconstruction group than in the delayed reconstruction group. In fact, 28% of patients in the immediate reconstruction group required an additional flap to correct a distorted contour caused by flap shrinkage or severe flap contraction. These findings indicate that delayed reconstruction is preferred in patients who are candidates for breast reconstruction with a free TRAM flap and need postmastectomy radiation therapy.

References:
1. Spear SL, Onyewu C. Staged breast reconstruction with saline-filled implants in the irradiated breast: recent trends and therapeutic implications. Plast Reconstr Surg. 2000;105:930-942.
2. Tran N, Chang D, Gupta A, et al. Comparison of immediate and delayed free TRAM flap breast reconstruction in patients receiving postmastectomy radiation therapy. Plast Reconstr Surg. 2001;108(1):78-82.


A 56-year-old woman comes to the office for routine follow-up 10 days after undergoing skin-sparing right modified radical mastectomy and immediate breast reconstruction with a subpectoral tissue expander. Physical examination shows a 2 _ 3-cm area of frank necrosis of the lower lateral mastectomy skin flap. The tissue expander in this area is not covered by muscle, but it is not exposed and there are no signs of infection. Which of the following is the most appropriate next step in management?

(A) Admission to the hospital for intravenous administration of antibiotics and observation
(B) Debridement of necrotic tissue and primary closure
(C) Debridement of necrotic tissue and removal of the tissue expander
(D) Initiation of tissue expansion by instillation of 100 mL of saline into the tissue expander
(E) Oral administration of an antibiotic and follow-up in one week

The correct response is Option B.

For this patient, the most appropriate next step is to debride the necrotic tissue of the mastectomy skin flap using sterile technique and then perform primary closure of the resulting wound. This management minimizes the risk of infection and of exposure of the tissue expander.
Oral or intravenous administration of an antibiotic does not prevent eventual exposure and infection of a breast tissue expander that is covered with nonviable soft tissue. Initiation of tissue expansion in a mastectomy skin flap with frank necrosis risks dehiscence of the mastectomy wound and exposure of the tissue expander.

Removal of the tissue expander is not necessary because it is not infected at this time. If the skin flap necrosis can be debrided while the sterility of the tissue expander is maintained, the resulting wound can undergo primary closure and the breast reconstruction can be preserved. If the pectoralis major or serratus anterior muscle were covering the tissue expander in the necrotic area of the skin flap, this necrotic tissue could be managed nonoperatively by allowing it to slough and by performing regular dressing changes while secondary healing occurs.


References:
1. Grotting J. Reoperation following implant breast reconstruction. In: Reoperative Aesthetic & Reconstructive Surgery. Vol. 2. St. Louis, MO: Quality Medical Publishing; 1995:1032.
2. Spear S, Howard M, Boehmler J, et al. The infected or exposed breast implant: management and treatment strategies. Plast Reconstr Surg. 2004;113:1634-1644.



A 14-year-old girl has absence of the nipple and lack of development of the right breast. The left breast has normal shape and normal nipple-areola complex and fits a B-cup brassiere. Family history includes normal breast development in the parents and siblings. On physical examination, both pectoralis muscles are present and fully developed. No abnormalities of the hands are noted. Which of the following is the most likely diagnosis?

(A) Anterior thoracic hypoplasia
(B) Congenital absence of the breast
(C) Hypoplasia of the breast
(D) Poland syndrome
(E) Tubular breast deformity


The correct response is Option B.

Congenital absence of the breast is defined by the absence of the nipple and mammary gland. This rare genetic condition is highly heterogeneous in presentation and inheritance.

Anterior thoracic hypoplasia is defined by unilateral sinking of the anterior chest wall, hypoplasia of the breast, superior location of the nipple-areola complex, and normal pectoralis muscles. In hypoplasia of the breast, both nipples are present. In Poland syndrome, the defining feature is partial or complete aplasia of the sternocostal head of the pectoralis muscle and deformity of the breast and upper extremity. Tubular breast deformity involves constriction at the base of the breast, hypoplasia of the breast, and herniation of tissue into the nipple-areola complex.


References:
1. Spear SL, Pelletiere CV, Lee ES, et al. Anterior thoracic hypoplasia: a separate entity from Poland syndrome. Plast Reconstr Surg. 2004;113(1):69-77.
2. Lin KY, Nguyen DB, Williams RM. Complete breast absence revisited. Plast Reconstr Surg. 2000;106(1):98-101.



A 13-year-old girl is brought to the office by her parents because her left breast is not developing. On examination, both nipples and areolae are present. The breasts are asymmetric; the left breast is considerably smaller. The left anterior axillary fold is absent. This patient is most likely to have which of the following additional developmental differences?

(A) Ambiguous genitalia
(B) Craniosynostosis
(C) Microtia
(D) Pectus excavatum
(E) Syndactyly

The correct response is Option E.

This patient has Poland syndrome, which is characterized by unilateral breast or nipple hypoplasia, unilateral absence of the sternal head of the pectoralis major muscle, absence of the pectoralis minor muscle, and ipsilateral syndactyly or hypoplasia of the ipsilateral extremity. In severe Poland syndrome, rib anomalies also occur.

Ambiguous genitalia, craniosynostosis, microtia, and pectus excavatum are not associated with Poland syndrome.

References:
1. Roth D. Thoracic and abdominal wall reconstruction. In: Aston SJ, Beasley RW, Thorne CH, eds. Grabb & Smith’s Plastic Surgery. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 1997:1023-1030.
2. Bostwick J. Reconstructive problems. In: Bostwick J, ed. Plastic and Reconstructive Breast Surgery. Vol 2. 2nd ed. St. Louis, MO: Quality Medical Publishing; 1999:1530-1533.



A 56-year-old woman with recurrent cancer of the right breast and no evidence of distant metastatic disease is scheduled to undergo completion mastectomy five years after undergoing lumpectomy (segmental mastectomy) for stage II carcinoma with radiation. In this patient, risk of complications is highest with which of the following methods of immediate breast reconstruction?

(A) Free superior gluteal artery perforator (SGAP) flap
(B) Free TRAM flap
(C) Latissimus dorsi myocutaneous flap with implant
(D) Pedicled TRAM flap
(E) Tissue expansion

The correct response is Option E.
In a patient with a previously irradiated breast, reconstruction with a tissue expander followed by a permanent implant (expander/implant) has a higher rate of complications than does reconstruction with any autologous tissue.


The latissimus dorsi myocutaneous flap, pedicled TRAM flap, free TRAM flap, and free SGAP flap are autologous methods of breast reconstruction that bring in new unradiated tissue to reconstruct the breast.


One study showed that previous radiation exposure was a significant risk factor for major complications after breast reconstruction with an expander/implant but not after reconstruction with a TRAM flap. Another study showed that breast cancer patients who underwent radiation and reconstruction with an expander/implant had a significantly higher rate of complications than patients who had radiation and breast reconstruction with a TRAM flap. These findings remained the same whether radiation exposure occurred before or after breast reconstruction.


References:
1. Bostwick J. Tissue expansion reconstruction. In: Bostwick J, ed. Plastic and Reconstructive Breast Surgery. 2nd ed. St. Louis, MO: Quality Medical Publishing; 1999:818-1420.
2. Lin K, Johns F, Gibson J, et al. An outcome study of breast reconstruction: presurgical identification of risk factors for complications. Ann Surg Oncol. 2001;8:586-591.
3. Chawla A, Kachnic L, Taghian A, et al. Radiotherapy and breast reconstruction: complications and cosmesis with TRAM versus tissue expander/implant. Int J Radiat Oncol Biol Phys. 2002;54:520-526.