Non Traditional Methods for Breast Reconstruction

• We elected to discuss a topic that focuses on non-traditional methods for breast reconstruction.  
• There is already a great quick hits pod cast regarding breast reconstruction, which is a exceptional in-service review for implant based and flap reconstruction.  
• While at Emory (our institution, we perform a significant amount of implant based and flap reconstruction), we also utilize other non-traditional methods.  

• Today, we plan to discuss the following topics: 
  1. Pre-operative evaluation, patient discussions, and how to present different reconstructive methods with your patient
  2. Oncoplastic breast reconstruction
  3. Goldilocks breast reconstruction 

 
Pre Operative considerations:  

1. Breast surgeon and plastic surgeon relationship
   – it is very important to have a good relationship with your breast surgeon. Not only does this assist with the referral base, but also helps with the type of reconstruction that is best for your patient depending the type of tumor extirpation and can greatly affect the cosmetic outcome.  

• For example: does your patient meet criteria for traditional BCT, in which oncoplastic reconstruction is a consideration 
• Mastectomy/lumpectomy skin flap thickness 

• We often try to work with our breast surgeons as a team, and are involved with the pre-operative markings, therefore, helps to ensure that the incision used for tumor extirpation does not interfere with the planned reconstruction  
• Obviously, in these operations, the foremost goal is for adequate oncologic resection; but being involved pre-operatively helps with cosmetic result  

1. Patient characteristics
   Patient characteristics that can affect reconstructive outcomes: 
   – has the patient already received adjuvant therapies, or do they need adjuvant therapies 
   – XRT is needed for patients undergoing BCT 
   – comorbidities: DM, HTN, obesity, smoking status 
   very important to not overlook these and pre-operatively maximize. As oncoplastic surgery or goldilocks reconstruction is typically less surgery and anesthesia time for the patient, this is a consideration when discussing reconstruction types; however, these methods require more surgery than traditional BCT, and therefore want to prevent complications, especially in patients who need adjuvant therapies 
   – Breast measures: 
   Nipple to notch
   nipple to IMF 

Degree of ptosis 
– evaluation of the CL breast
– patient expectations and goals: does the patient want a simultaneous contralateral symmetrizing procedure, what breast size do they want, do they desire natural ptosis or a more augmented look. 
– discuss potential complications: such as nipple necrosis, skin flap necrosis, and delayed wound healing.   

• Evaluation for potential donor sites to present all options: tummy, back, thighs, buttock  

Dr Cheng: what other aspects are included in your pre-operative discussion? 

If a patient has an unrealistic expectation, how to you set expectations with them? 

Other ?s: 

(rosie any other questions here)

• When is the appropriate timing for meeting with patients to discuss their options? Soon after diagnosis vs after breast surgery has decided appropriate treatment course etc 
• How do you approach oncoplastic surgery in patients with increased risk of thrombosis such as sickle cell or tamoxifen? 

Indications for BCT

Breast conservation therapy – involves lumpectomy /partial mastectomy with radiation therapy for the treatment of breast cancer. Native breast tissue is obviously conserved compared to traditional TM. 
This technique became popularized in the 90s in the treatment of early-stage breast cancer after multiple Randomized controlled trials demonstrated that there was no difference in overall survival between the two extirpative methods, although some studies suggest an increase in local recurrence in the BCT group. 

Important to have multi-disciplinary tumor board discussions for these patients, including breast, PRS, Rad onc and med onc, etc

Breast Conservation Therapy Contraindications: 

• Multicentric disease  

• PMH Rx to chest wall/breast 
• Diffuse microcalcifications on mammogram 
• Persistent deep margin despite re-excision  
• Pregnancy: of which contra-indicated due to need for XRT 
• Relative contraindications:  

• large tumor in a small breast – some literature extrapolates this to tumor size of about 5 cm, although an exact criteria hasn’t been established.  
• Collagen vascular disease, less toleration of XRT 

What is OBS: 

Oncoplastic breast is a subset of BCT in which volume displacement and replacement techniques are employed to improve the outcome and minimize the BCT deformity.

• high incidence of a breast conservation deformity, (30-40%).  
• BCT deformity dependent of tumor size and location 
• Tumor resection >10-20% or in central, inferior or medial locations associated with greater deformity 

Breast Aesthetic goals take into consideration breast symmetry, shape, scar, location of IMF and location of NAC.
– when performing OBS: tumor:breast volume ratio is the most important consideration 

Algorithms have been suggested for OBS by Van Paridon and colleagues 

1. Small breasts with small defect and minimal asymmetry  
   Local parenchymal rearrangement or local flap  

1. Moderate breast asymmetry, with some degree of ptosis
   Mastopexy 

1. Larger breasts with significant asymmetry
   reduction mammaplasty and auto-augmentation procedures; often with with CL symmetrizing mammaplasty  

Examples of local flaps that can be used to fill defects:
– lateral TD flap
– Latiss or TDAP flap 
– intercostal perforator flaps 

– Superior epi perforator flaps  

At our institution, we commonly preform Oncoplastic reductions with CL symmetrizing procedures. Depending on patient population, patients w/ pendulous breasts benefit from the reduction mammaplasty. After oncologic resection preformed, reduction techniques are utilized. Further, the CL breast is then reduced to match the breast. This provides the patient not only with adequate tumor resection, but also provides the benefits of a reduction, (Ie, decreased back/neck pain, decrease bra strip irritation, decreased irritation from interiginous folds, etc) with also a cancer risk reduction of 30% in the CL breast. 

As we know, the risk of an occult breast cancer in <1 % in patients who are undergoing reductions not in the setting of cancer; however, important to note that there is actually about a 5% risk of occult cancer in the CL breast when a reduction is preformed. 

It is important to make the breast that is to receive XRT larger, about 15%, to prevent contraction/fibrosis 2ndary to XRT. 

Dr. Cheng:
– when you choose OBS, when you choose CL procedure, pedicle type, etc. 

• Risks of contralateral symmetry procedure at the time of initial operation versus delayed (aesthetic and complication risks) 

Other benefits of OBS: 

– promotes cosmesis: 2 large meta-analyses have shown good cosmesis in 85-90% of patients, although what appears to be a major limitation in the literature is lack of objective evaluation 

• Larger tumor resections and decreased positive margins compared to BCT 
• Less subsequent procedures, less re-excision for + margins 
• In a recent series published by Dr. Losken et al at Emory –decreased number of total surgeries to reach definitive reconstruction compared to TM with implants or flap 
  2.4 vs 5.8. 
  Less complication in the oncoplastic subset  
• Learning curve with the technique  
• Psychosocial benefits  

Timing: typically preformed in an immediate fashion to avoid operating on a breast that has received XRT. 

Cons: compared to BCT, is more surgery – which can be associated with increased complications, which is an important consideration to prevent delay to chemo/rads – which can play an important consideration for survival
further, is a relatively high risk population, as these patients are to receive radiation, which obviously affects aesthetic result, tissue quality, symmetry, wound healing, etc. 

Goldilocks: 

• First described in 2012 – by Dr’s Heather Richardson and Grace Ma (of note, Grace Ma, private Plastic surgeon in ATL and former Emory PRS Grad) 
• Form of breast recon utilizing patients native tissue. Wise patterned incision utilized, the remaining mastectomy skin flaps are then de-epithelialized and rotated to create a small central breast mound 
• Use: patients s/p SSM, w/ comorbidities, In which tradition reconstructive techniques would be high risk, breast ptosis, or older patients who don’t want extensive reconstructive procedures,  
• Named Goldilocks: based on the fairytale as an intermediate form of reonstruction, seeking to reach an outcome that is “just right” 

• Strongly urge you all to read the original article written by Dr. Ma, published in the International Journal of surgery in 2012, as it is a relatively new technique for breast reconstruction.   
• Initial publication looked at 50 breasts, in which had a very low complication profile, none of which required a return to the OR  
• More recent literature looks at this technique in very obese patient population
  BMI >40 and BMI >50 in conjunction with FNG
  Implant then place sub-pec >3months following goldilocks procedure  

Demonstrated reliable method to bridge to implant based reconstruction in this high risk population.  

• Data of 53 patients, average BMI 33
  low complications: <10%  

Dr. Cheng –

• Do you tend to have contour deformities? 
• How many patients are satisfied with the appearance and forgo secondary implants? 
• Advantage over tissue expander if it is a bridge to implant? 

• Do you ever use it as a dual plane over prepec implants? 

Overview: 
Dr. Cheng – how to you speak to your patient to discuss pursuance of Goldilocks?

• Obviously if patients choose UL, high risk of severe asymmetry 
• Frequency of contralateral prophylactic mastectomy

Sources: 
Umberto Veronesi 1, Natale Cascinelli, Luigi Mariani, Marco Greco, Roberto Saccozzi, Alberto Luini, Marisel Aguilar, Ettore Marubini. Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. 
J Surg Tech Case Rep. 2011 Jan-Jun; 3(1): 1–4. doi: 10.4103/2006-8808.78459 PMCID: PMC3192521 PMID: 22022642 

Breast Conserving Therapy: A surgical Technique where Little can Mean More . Ganiyu A. Rahman 

K B Clough 1, S S Kroll, W Audretsch. An approach to the repair of partial mastectomy defects. PRS. 1999 Aug;104(2):409-20. 

Van Paridon. Oncoplastic breast surgery: Achieving oncological and aesthetic outcomes. J of Surg Oncology. 2017.  

Losken, Brown. How to Optimize Aesthetics for the Partial Mastectomy Patient. ASJ. 2020 

Losken A, Pinell XA, Eskenazi B. The benefits of partial versus total breast reconstruction for women with macromastia. Plast Reconstr Surg. 2010;125(4):1051-1056. 

H Richardson, Ma G. The Goldilocks Mastectomy. I J of Surgery. 2012.  

Schwarts. Based Breast Reconstruction in the Morbidly Obese. PRS GO 2017.