British Journal of Plastic Surgery (2001 ), 54, 227-231 �9 2001 The British Association of Plastic Surgeons doi: 10.1054/bjps.2000.3538

B R I T I S H J O U R N A L OF

How many procedures to make a breast?

A. D. Malyon, M. Husein and E. M. Weiler-Mithoff

Plastic Surgery Unit, Canniesburn Hospital, Glasgow, UK

P L A S T I C S U R G E R Y

SUMMARY. The construction of a new breast after mastectomy involves fashioning the breast mound and creating a projecting nipple and a coloured areola. This should involve three episodes for a patient, but is this the experience of patients embarking on breast reconstruction? We identified 177 patients who had undergone breast reconstruction between 1 September 1997 and 31 March 1999. The clinical records for 164 of these patients were found and the data summarised. The techniques, complications and other ancillary procedures experienced by this group of patients are presented. Multiple procedures are likely to be required to complete breast reconstruction, and the patient should be so counselled from the outset. Particular problems may be encountered with each technique and this should be borne in mind when selecting a procedure for each patient, especially in the context of immediate reconstruction where avoiding any delay to adjuvant treatment is a consideration. �9 2001 The British Association of Plastic Surgeons

Keywords: breast reconstruction, nipple reconstruction, complications.

The demand for breast reconstruction after mastectomy appears to be increasing dramatically: only 24 breast reconstructions were performed at Canniesburn Hospital in 1987 against the much larger number found in this study. The procedures involved are not all straightfor- ward, can give a variable quality of outcome and may have complications. In order to improve the counselling of patients considering this type of surgery we have reviewed all breast reconstructions performed in both the Plastic Surgery unit and the General Surgical units between 1 September 1997 and 31 March 1999. In total, 177 cases of breast reconstruction were identified and the records for 164 of these were obtained for review.

The practice of this unit is to offer reconstruction using an implant alone (placed in the submuscular plane), an implant with a latissimus dorsi flap, an autologous latissimus dorsi flap or free tissue transfer (usually from the abdomen, based on either the superficial or deep infe- rior epigastric vessels, sparing muscle where possible1). The final choice of reconstructive method will depend upon the likelihood of postoperative radiotherapy, the general fitness of the patient for surgery, the availability of the techniques in a particular patient and the personal preference of the patient. Surgery to the contralateral breast is usually planned at the initial consultation but may also be discussed and held for a later date according to the patient's wishes. The timing of surgery is decided in conjunction with the general surgeon and the patient. The venue for the surgery may be the General Surgical unit or the Plastic Surgical unit, depending on the timing and type of surgery involved and is decided jointly with the general surgeons.

The mechanism for referral of cases for consideration for immediate reconstruction is via an 'immediate-access breast clinic'. This clinic runs on a weekly basis and offers a 'next clinic' appointment when any general

surgeon refers a patient considering an immediate recon- struction. Once the patient has been seen, detailed plan- ning of where the surgery will be performed and which personnel will be required can proceed. It is normal practice to perform surgery within 2 weeks of the breast- clinic appointment.

Nipple reconstruction is offered to all patients once construction of the breast mound is complete and a period of around 3-6 months has passed to allow gravity to act on the new breast. Plastic nipples with adhesive, nipple sharing and local flaps with tattooing are offered.

Methods

Identification of cases

Breast reconstructions performed at the Plastic Surgery unit were identified from the hospital coding database by trawling for procedures coded as either breast reconstruc- tion or nipple reconstruction. The coding of cases is per- formed by the operating surgeon, all case notes pass through the coding department at the end of a patient episode and the codes for breast reconstruction and nipple reconstruction should therefore prove sufficient to identify all cases. For procedures performed away from the Plastic Surgery unit, a second hospital database was used. This database relies on the surgeon returning from a procedure performed elsewhere recording the details of the case. This database is therefore regarded as more likely to return incomplete data but still represents the simplest method of retrieving this data. In all, 177 cases of breast reconstruc- tion were identified during the study period. Only breast reconstructions commenced during this period were included in the study; reconstructions already underway were excluded. Details of all cases were then recorded in a PC database (MS Access) and analysed using MS Excel.

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228 British Journal of Plastic Surgery

Table 1 Definitions of categories of complication

Category Definition

none minor

moderate

severe patient request

no record of any adverse event adverse event not requiting any surgical intervention adverse event requiring surgical intervention complete loss of reconstruction patient requests surgical adjustment of reconstruction or opposite breast

Table 3 Uptake of nipple reconstruction (expressed as a percentage) broken down by type of flap

Flap type Autologous Awaited Not needed Not wanted Total

DIEP 38.3 51.1 4.3 6.4 100.0 latissimus dorsi 26.0 42.0 6.0 26.0 100.0 none 20.0 46.0 18.0 16.0 100.0 SGAP 0.0 80.0 20.0 0.0 100.0 SIEA 33.3 66.7 0.0 0.0 100.0 TRAM 16.7 50.0 16.7 16.7 100.0 all flaps 26.8 48.2 9.8 15.2 100.0

Table 2 Summary of type of surgery and mean age of patients

Flap Mean age Flap Implant § Implant Total (years) only flap only*

DIEP 43.70 47 47 latissimus dorsi 48.78 31 19 50 none 45.33 50 50 SGAP 37.00 5 5 SIEA 43.50 6 6 TRAM 42.33 6 6 all flaps 45.48 95 19 50 164

r

*All implants were placed submuscularly.

Classifications used

The only data that required classification in order to facil- itate data analysis were those regarding postoperative com- plications. It was decided to use a simple classification that reflected the effect of the complication on the patient and her reconstruction. Definitions of the categories are listed in Table 1. The 'patient requests ' category was included as this was seen as an event leading to a further surgical episode.

R e s u l t s

We identified 177 cases of breast reconstruction, and the notes for 164 of these were found. The mean age of patients undergoing reconstruction was 45.48 years (range: 17-71 years). Immediate reconstructions accounted for 101 cases, and 66 patients were treated at the refer- ring unit rather than the Plastic Surgery unit (all were immediate reconstructions). The mean follow-up was 10 months (range: 2-19 months). There appears to be a trend towards immediate reconstruction over the study period. In the first six months of the study period 55% of the reconstructions were immediate, rising to 57% and then to 75% in the two following periods.

Of the 164 reconstructions, 142 were performed after mastectomy for established breast cancer, with a further 14 following prophylactic mastectomy, the remainder being for congenital problems. The initial referral was from the general surgeon in 136 cases, with a further 13 from the oncologist. Six referrals were also seen from the breast-care nurse, with the remainder from general practi- tioners. The type of surgery performed is summarised in Table 2.

Table 4 Breakdown of complications by procedure (expressed as percentages)

Complications (%)

Flap None Minor Moderate Severe Patient Total request

DIEP 23.4 23.4 36.2 0.0 17.0 100.0 latissimus dorsi 34.0 36.0 8.0 4.0 18.0 100.0 none (implant only) 50.0 4.0 16.0 18.0 12.0 100.0 SGAP 20.0 0.0 20.0 60.0 0.0 100.0 SIEA 16.7 33.3 33.3 0.0 16.7 100.0 TRAM 0.0 16.7 66.7 0.0 16.7 100.0 Total 33.5 20.7 22.0 8.5 15.2 100.0

There appears to be no particular skew of the different groups by age. Nipple reconstruction is offered to all patients once construction of the breast mound is com- plete. This is always several months after the first pro- cedure and therefore many patients are still to reach a point where a decision can be made. The uptake of nip- ple reconstruction in all patients in the study is shown in Table 3.

Although at first sight there appears to be a marked difference in the uptake of nipple reconstruction accord- ing to procedure, this conclusion must be tempered by the large number of patients in all groups remaining undecided about proceeding.

An analysis of the complications, broken down according to the groups already described, is shown in Table 4.

The problems experienced in the total-loss group are detailed in Table 5. Although there were two (4.0%) severe complications in the group who had undergone reconstruction using latissimus dorsi flaps, in both these patients the loss was of the implant rather than the flap. There did not appear to be any significant difference in the incidence of smoking, the mean age or, indeed, any other likely predictive factor between the severe-loss group and the other implant-only reconstruction patients that might explain the high number of failures in the implant-only group.

In patients undergoing free tissue transfer moderate complications were usually related to the anastomoses or partial loss of the flaps. Partial necrosis of the mastec- tomy skin flaps was also a problem. In the implant-only group most problems were related to migration or expo- sure of the filling port. Two patients presented with

How many procedures to make a breast? 229

Table 5 Problems leading to total loss of reconstruction

Flap type Complication

latissimus dorsi latissimus dorsi

n o n e

n o n e

n o n e

none none

none none none none SGAP SGAP SGAP

implant extrusion, no flap loss loss of implant, flap fine, implant replaced 4 months later infection, implant removed complete loss, wound breakdown infected implant removed and replaced 6 months later exposed implant following revision implant lost after full-thickness cigarette burn 18 months postoperatively infection, explantation extrusion of implant, removal necrosis of skin flaps with exposure of expander extrusion, explantation total loss total loss total loss

Table 6 Minor complications encountered

Flap type Complication

DIEP

DIEP

DIEP DIEP DIEP DIEP DIEP DIEP DIEP DIEP latissimus latissimus latissimus latissimus latissimus

latissimus latissimus latissimus latissimus latissimus latissimus latissimus latissimus latissimus latissimus latissimus latissimus latissimus none none

SIEA SIEA TRAM

small axillary collection aspirated, awaiting minor adjustment minor donor wound problems, revision of flap at time of NAC reconstruction minor delayed wound healing minor abdominal wound dehiscence minor wound problems minor haematoma, no surgery required delayed wound healing abdominal seroma wound infection, pulmonary embolism small area of delayed healing in abdominal wound

dorsi donor-site seroma dorsi seroma, aspiration, awaiting adjustment dorsi seroma, aspiration dorsi small area of delayed healing, donor-site seroma dorsi donor-site seroma, minor dog-ear revision at time of

NAC reconstruction dorsi seroma, aspiration dorsi wound infection after nipple share dorsi seroma dorsi seroma, slow healing dorsi wound infection dorsi seroma dorsi loss of tip of flap, delayed healing dorsi grade III capsule, not currently wanting surgery dorsi seroma, aspiration dorsi seroma, aspiration dorsi seroma, aspiration dorsi seroma, slow wound healing dorsi seroma, aspiration

slow healing uneven expansion of breast (prior radiotherapy), previous bilateral augmentation minor delayed healing of abdominal wound donor-wound infection, delayed healing wound infection

capsule format ion wi th in the l imited fol low-up per iod o f this study. It is wor thy of note that very few abdomina l -wal l compl ica t ions were seen in this series fol lowing free t issue t ransfer f rom the abdomen . In the minor -compl ica t ion group, some free-flap pat ients had mino r delays in w o u n d

Table 7 Moderate complications

Flap type Complication

DIEP DIEP

DIEP DIEP

D1EP D1EP D1EP

DIEP D1EP

DIEP

DIEP

DIEP

DIEP

DIEP

DIEP

latissimus dorsi latissimus dorsi

latissimus dorsi

latissimus dorsi

none

n o n e

n o n e

n o n e

n o n e

n o n e

n o n e

n o n e

SGAP SIEA SIEA

TRAM TRAM TRAM TRAM

haematoma, free nipple grafts lost re-exploration of anastomosis, flowing OK, no flap loss revision of abdominal scar venous anastomosis redone, still poor flow, partial flap loss partial flap loss, two debridements donor wound breakdown, debrided and closed inguinal hernia (resolved spontaneously), abdomi- nal-wound sinus small area of flap loss two re-explorations of anastomosis with success, some loss of flap volume partial flap loss, volume insufficient, implant inserted then extruded flap did not heal to surrounding tissue, further pedicled latissimus dorsi required cavity deep to breast reconstruction, debridement (fat necrosis and infection) debridement and split-skin graft of abdominal and breast wounds required two re-explorations for haematoma, one revision of venous anastomosis, late debridement of partial (< 10%) loss, later minor adjustments sinus requiring excision, minor adjustments to reconstructed breast partial loss of mastectomy flap, 'twitching breast' tethering of implant to latissimus dorsi, thora- codorsal nerve division outcome awaited grade III capsule, capsulotomy, subsequent revi- sion with contralateral mastopexy lateral migration of reconstruction requiring repo- sitioning, seroma implant too high, awaiting change of implant and repositioning port turned requiring re-exploration port eroded through skin, resited port required turning, adjust implant partial loss of skin flap, debrided and closed grade III capsule, malposition, capsulotomy tube leak, port turned, post-tranmatic seroma partial loss of right nipple (flee graft), subsequent reconstruction necrosis of mastectomy skin flap, debridement lymph collection, insertion of drain loss of medial 25% of flap, debrided and closed primarily partial loss (-20%) hernia revision of flap inset minor wound breakdown, large seroma of abdomen and breast

hea l ing (usual ly o f the a b d o m i n a l wound) . In those w h o had u n d e r g o n e l a t i s s imus-dors i r econs t ruc t ion the m o s t c o m m o n m i n o r c o m p l i c a t i o n was se roma fo rmat ion . Ful l deta i ls of the p r o b l e m s e x p e r i e n c e d by these pa t ien t s are g iven in Tables 6, 7 and 8.

Finally, the n u m b e r o f p rocedure s r equ i red to c o m - ple te the r econs t ruc t i on or u n d e r g o n e by the end o f the s tudy pe r iod was recorded . Table 9 shows a b r e a k d o w n o f the n u m b e r o f p rocedure s u n d e r g o n e tak ing in to accoun t the n ipp le r econs t ruc t i on status.

230 British Journal of Plastic Surgery

Table 8 Reasons for patient requests

Flap type Complication

latissimus dorsi

latissimus dorsi none DIEP

DIEP latissimus dorsi latissimus dorsi latissimus dorsi TRAM DIEP

DIEP

latissimus dorsi

none DIEP latissimns dorsi none DIEP none latissimus dorsi none SIEA latissimus dorsi none

DIEP DIEP

adjustment of reconstructed breast at time of mastopexy ('double bubble') droop, bilateral mastopexy wants contralateral augmentation bulges revised, haematoma after revisionary surgery, delayed wound healing minor adjustments required asymmetry asymmetry, needs contralaterai reduction required revision wants revision of breast, no surgical problems required contralateral augmentation, scar revisions to breast and abdomen at time of NAC reconstruction required augmentation of reconstructed breast (second stage), first implant total loss due to infec- tion, second successful liposuction of dog ears, implant inserted at NAC reconstruction wants replacement with DIEP flap delayed healing, required subsequent revision droop, bilateral mastopexy adjustment required minor adjustments required adjustment required minor adjustment required, seroma at flap donor site considering free tissue transfer unhappy with appearance of reconstruction wants contralaterai reduction very unhappy with appearance, implant exchanged, 'twitching breast' minor adjustment to flap awaiting minor adjustments

Table 9 Number of procedures broken down by uptake of nipple reconstruction

Number of procedures

Flap type Nipple 1 2 3 4 5 6 Totals

DIEP

latissimus dorsi

none

SGAP

SIEA

TRAM

underway 10 6 2 awaited 10 9 4 1 not wanted 2 1 1 1

underway 2 10 1 awaited 15 4 2 not wanted 14 1 1

underway 4 3 3 awaited 12 6 5 not wanted 9 5 2 1

underway awaited 4 not wanted 1

underway awaited 2 not wanted

underway awaited 2 not wanted 2

1 1 2

18 24 5

47 13 21 16 50 10 23 17 50 0 4 1 5 2 4 0 6 1 3 2 6

D i s c u s s i o n

A series of 164 breast reconstructions is presented. The immediately obvious feature is that in over half the patients in the series two or more procedures were required. This is in a series with limited follow-up where further procedures will be required for some of these patients, making the final tally higher still. Obviously, three procedures will be required to achieve a complete reconstruction (breast mound reconstruction, nipple reconstruction and nipple areola tattooing) but we have found a significant number of patients requesting further surgery to achieve better symmetry or to revise scars. Even leaving aside these possibly aesthetic procedures, 30% of all patients undergoing breast reconstruction required at least one further visit to theatre for a compli- cation of some kind. These complications were not lim- ited to the patients undergoing the most complex surgery, with a relatively high rate of complications in the group undergoing reconstruction using implants alone. This group were studied in greater detail and did not show a difference in any obvious patient factor (age, smoking status, preoperative general health) from those who had no complications. The influence of radiotherapy may have some part to play in these problems. 2

The number of immediate reconstructions being per- formed has implications for resources. Immediate recon- struction has to be performed at the time of mastectomy, making planning of these cases difficult. Clinically, rela- tions between general surgeons and plastic surgeons are excellent, with cooperative effort made to achieve the right reconstruction for each patient at the right unit and at the most appropriate time. The effect of this is that the plastic surgeon must be available to attend the general surgeon's theatre sessions (or vice versa) at relatively short notice if the request for immediate reconstruction is not to delay the mastectomy and any adjuvant treatment that the patient may require. Indeed, the apparently high complication rate seen with simple implant reconstruc- tions in this series may suggest that alternative recon- structions to the apparently simple 'implant only' would be most suitable in this setting. In the present finance-aware environment it should be borne in mind that in addition to any psychological benefit claimed for immediate reconstruction there is also a significant reduction in cost when compared with delayed reconstruction) There may also be another funding issue, in that if the plastic sur- geon attends the General Surgery unit to perform a reconstruction, does this procedure count as plastic surgery or general surgery, and where are the financial resources directed subsequently?

The patients who suffered total loss of their recon- struction were examined in more detail and appeared to have had no predictive factors preoperatively. One of the implant losses (infection following a full-thickness ciga- rette burn 18 months postoperatively) could be consid- ered unfortunate, and one loss followed revisionary surgery, but the remainder were lost in the early postop- erative period. The rate of implant loss in this study is at the upper end of the range reported from other studies of between 6.1%4 and 5 16.5%. The SGAP flaps that were lost all occurred early in the experience of this technique

How many procedures to make a breast? 231

at this unit and hopefully represent problems with the 'learning curve' seen with any technique. Since the study period ended this technique has been performed with more success.

Closer inspection of Table 9 gives the most insight into the number of procedures required. Any patient who is 'awaiting' nipple reconstruction (i.e. has yet to decide whether to proceed or is not yet ready) should ideally have had only one procedure, whereas those where reconstruction of the nipple is underway would be expected to have undergone two or three procedures. Our results show that 17/47 (36%) DIEP-flap patients, 8/50 (16%) latissimus-dorsi-flap patients and 21/50 (42%) implant-only patients who had not commenced nipple reconstruction had already undergone two or more proce- dures. Some of these procedures were due to patient requests rather than complications requiring reoperation. These requests occurred at varying times after recon- struction and may represent 'upgrading' of the expecta- tions of patients who initially had relatively low demands of the surgery. Also of interest is the uptake of nipple reconstruction. Of the implant-only patients 17/50 (34%) opted not to undergo any nipple reconstruction, com- pared with 16/50 (32%) in the latissimus dorsi and 5/47 (11%) in the DIEP groups. Although there appears to be a highly significant difference between the groups this should be accepted with some caution as the largest group of patients were still to decide whether or not to proceed with nipple reconstruction. If, however, the dif- ference is real then this could contribute to the slightly higher rate of patient requests seen in the patients under- going DIEP-flap reconstruction as they may have higher expectations of the reconstruction. The mean age of the patients opting not to proceed with nipple reconstruction was significantly higher (p=0.0001, Student's t-test) than the remainder of the study group.

Breast reconstruction is a complex undertaking, which may require several procedures to achieve the final goal of a new breast that is symmetric with the remaining side and bears a nipple. Adjustments to the reconstructed breast and the remaining breast may be required. More than one procedure should be expected from the outset. In selecting procedures for immediate reconstruction it is

important to ensure that there is no delay to any adjuvant treatment; from our series an autologous latissimus dorsi reconstruction seems to fit this criterion best, as it had the lowest rate of reoperation and the majority of the minor complications were donor-site seromas (which need not delay chemotherapy or radiotherapy). Our series shows that there are a significant number of patients undergoing reconstruction with an implant alone who are requiring further procedures, and this technique should perhaps be regarded with caution when planning an immediate reconstruction where adjuvant treatment may be required.

References

1. Arne~ ZM, Khan U, Pogorelec D, Planin~ek E Breast reconstruction using the free superficial inferior epigastric artery (SIEA) flap. Br J Plast Surg 1999; 52: 276-9.

2. Evans GRD, Schusterman MA, Kroll SS, et al. Reconstruction and the radiated breast: is there a role for implants? Plast Reconstr Surg 1995; 96: 1111-15.

3. Khoo A, Kroll SS, Reece GP, et al. A comparison of resource costs of immediate and delayed breast reconstruction. Plast Reconstr Surg 1998; 101: 964-8.

4. Camilleri IG, Malata CM, Stavrianos S, McLean NR. A review of 120 Becker permanent tissue expanders in reconstruction of the breast. Br J Plast Surg 1996; 49: 346-51.

5. Kroll SS, Evans GRD, Reece GP, et al. Comparison of resource costs between implant-based and TRAM flap breast reconstruc- tion. Plast Reconstr Surg 1996; 97: 364-72.

The Authors

A. D. Malyon FRCS(Plast), Consultant Plastic Surgeon

Plastic Surgery Unit, Royal Hospital Haslar, Gosport, Hampshire PO12 2AA, UK.

M. Husein, Registrar in General Surgery E. M. Weiler-Mithoff FRCS(Plast), Consultant Plastic Surgeon

Plastic Surgery Unit, Canniesbum Hospital, Switchback Road, Bearsden, Glasgow G61 1QL, UK.

Correspondence to Mr A. D. Malyon.

Paper received 3 March 2000. Accepted 16 October 2000, after revision. Published online 23 February 2001.