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Annals of Surgical Oncology 9:462-466 (2002)
© 2002 Society of Surgical Oncology

ORIGINAL ARTICLES

Skin-Sparing Mastectomy and Immediate Breast Reconstruction: A Prospective Cohort Study for the Treatment of Advanced Stages of Breast Carcinoma

Robert D. Foster, MD, Laura J. Esserman, MD, James P. Anthony, MD, Eun-sil S. Hwang, MD and Hoang Do, MD

From the Division of Plastic and Reconstructive Surgery (RDF, JPA, HD) and the Department of Surgery (LJE, ESH), the University of California, San Francisco, California.

Correspondence: Address correspondence and reprint requests to: Robert D. Foster, MD, University of California, San Francisco, Division of Plastic and Reconstructive Surgery, 350 Parnassus Ave., Suite 509, San Francisco, CA 94143-0932; Fax: 415-476-4001; E-mail: fosterr{at}surgery.ucsf.edu


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Background: Recent published series demonstrate the safety and effectiveness of skin-sparing mastectomy (SSM) with immediate reconstruction for the treatment of early-stage breast carcinoma. Although several reports have retrospectively evaluated outcomes after breast reconstruction for locally advanced disease (stages IIB and III), no study has specifically considered immediate breast reconstruction after SSM for locally advanced disease.

Methods: From 1996 to 1998, 67 consecutive patients with breast carcinoma underwent SSM with immediate reconstruction and were prospectively observed. From this group of patients, those with locally advanced disease (stage IIB, n = 12; stage III, n = 13) were analyzed separately. Tumor characteristics, adjuvant therapy, type of reconstruction, operative time, complications, hospital stay, and incidence of local recurrence and distant metastasis were noted.

Results: Breast reconstruction consisted of a transverse rectus abdominis myocutaneous flap (n = 22) or a latissimus flap plus an implant (n = 4). The median operative time was 5.5 hours; the average hospital stay was 5.2 days. Complications required reoperation in three patients (12%): partial skin flap necrosis in two and partial abdominal skin necrosis in one. Surgery on the opposite breast for symmetry was required in one patient (4%). Postoperative adjuvant therapy was not significantly delayed (median interval, 32 days). With a median length of follow-up of 49.2 months (range, 33–64 months), local recurrence was present in only one patient (4%), with successful local salvage treatment, and distant metastasis was present in four patients (16%).

Conclusions: SSM with immediate reconstruction seems safe and effective and has a low morbidity for patients with advanced stages of breast carcinoma. Local recurrence rates and the incidence of distant metastasis are not increased compared with those of patients who have had modified radical mastectomies without reconstruction.

Key Words: Skin-sparing mastectomy • Breast reconstruction • Advanced breast cancer


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
In 1991, Toth and Lappert1 introduced the term skin-sparing mastectomy (SSM) to describe an approach of maximizing skin preservation to facilitate breast reconstruction. In most cases, only the nipple/areola complex is visibly sacrificed, without additional scars across the breast; this maintains the inframammary fold and improves the cosmetic result2 (Fig. 1). The primary concerns surrounding the use of this technique have included the increased morbidity (e.g., skin flap necrosis) of a mastectomy that is technically more difficult to perform reliably and the risk of local tumor recurrence and delay of its diagnosis.



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  		FIG. 1. (A) Preoperative view of patient with right-sided breast carcinoma. (B) Postoperative view of the same patient after skin-sparing mastectomy with immediate reconstruction with a transverse rectus abdominis myocutaneous flap, nipple reconstruction, and tattooing.

 
Recently published series have demonstrated the safety of SSM with immediate reconstruction for the treatment of early-stage breast carcinoma.3,4 Local recurrence rates are comparable to those of patients with either a delay in their reconstruction or no reconstruction at all.3,5 With a median follow-up of 5 years, recurrence rates ranged from 0% to 7%. Furthermore, the diagnosis of local recurrences does not seem to be delayed. The indications for SSM in more advanced stages of breast cancer, however, remain undetermined, and in many centers SSM has been considered contraindicated.2,6

Additional concerns about the application of SSM with immediate reconstruction to locally advanced (stage IIB and III) cases of breast cancer center around adjuvant therapy, which is almost always a part of the treatment for locally advanced breast cancer. The concerns include (1) the risk that prolonged recovery from surgery will result in delays in postoperative therapy, (2) the risk that preoperative chemotherapy will impair wound healing, and (3) the effect of radiotherapy on flap healing and the esthetic result. Since 1996, we have prospectively observed all breast cancer patients at our institution undergoing SSM and immediate reconstruction. The purpose of this study was to evaluate the safety and efficacy of applying SSM and immediate reconstruction to patients with locally advanced stages of breast carcinoma.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
From 1996 to 1998, 67 consecutive patients at the Mt. Zion Breast Cancer Center undergoing modified radical mastectomy with immediate reconstruction were prospectively observed after undergoing SSM with either a transverse rectus abdominis myocutaneous (TRAM) flap or a latissimus myocutaneous flap plus an implant for reconstruction. Patients were all counseled before surgery on risks and benefits, pre- and postoperative expectations, and reconstructive options by a multidisciplinary team consisting of a general surgeon, plastic surgeon, oncologist, and nursing care specialist. Patients were able to examine photographs of patients who had undergone various types of reconstruction and were given the opportunity to speak with individuals who had chosen immediate reconstruction. Contraindications to SSM included only those cancers with either direct skin involvement or cancers too close to the skin to achieve adequate margins. The choice between a TRAM flap and the latissimus dorsi flap was based on the patient’s wishes and the nature of her abdominal donor site. If adequate tissue was available on the abdomen, a TRAM flap was preferred.

Ages ranged from 29 to 75 years (mean, 48 years). Preoperative staging was as follows: stage 0, n = 27; stage I, n = 10; stage IIA, n = 5; stage IIB, n = 12; stage IIIA, n = 9; and stage IIIB, n = 4. From this group of patients, those with locally advanced disease, defined as stages IIB and III, were analyzed separately and form the basis for this study. Tumor characteristics, adjuvant therapy, type of reconstruction, operative time, complications, hospital stay, and follow-up (including local recurrence and distant metastasis) were recorded. The median length of follow-up was 49.2 months (range, 33–64 months). The results for local recurrence rates, the interval to postoperative chemotherapy, and the incidence of distant metastasis were compared with historical data in the literature for patients who underwent modified radical mastectomies without reconstruction for stage IIB and III breast tumors.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Patient Characteristics and Treatments
The tumor characteristics of the 25 patients with locally advanced disease revealed that 48% of the tumors were estrogen receptor positive and that 60% of the tumors had an anaplastic nuclear grade (Table 1). The superficial tumor margin of the breast was measured on the pathology specimen and recorded for each patient. The average for all specimens was >.70 cm and was >1.0 cm for stage III tumors (Table 1). None of the patients had direct skin involvement. Only 52% of patients received preoperative chemotherapy (probably because the extent of breast disease was underestimated before surgery in several patients), whereas 92% of patients had postoperative chemotherapy (Table 2). In most cases, postoperative chemotherapy was begun by 1 month after surgery (Table 3). Forty-eight percent of the patients received postoperative radiotherapy (Table 2), which most patients could tolerate by 4 weeks after surgery as well. When compared with our own data for patients after modified radical mastectomy without reconstruction (median, 27 days), the postoperative time interval to start adjuvant therapy was not significantly different (median, 32 days; P > .05).


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  		TABLE 1. Age, stage of disease, and tumor characteristics in patients with locally advanced breast carcinoma (n = 25)
 

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  		TABLE 2. Treatment of patients with locally advanced breast carcinoma (n = 25)
 

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  		TABLE 3. Outcome for patients with locally advanced breast carcinoma (n = 25)
 
Breast Reconstruction: Outcomes and Complications
In all cases, SSM consisted of sacrificing only the nipple and areola at the level of the skin, with a periareolar incision. Breast reconstruction included TRAM flaps in 84% of patients and latissimus myocutaneous flaps with an implant in 16% of patients. In nine cases, nipple reconstruction was performed at the time of the initial breast reconstruction. The operative time averaged 5.5 hours, including the mastectomy; the average hospital stay was 5.2 days, and only one patient required surgery to the opposite breast for symmetry. In those patients who received radiation after reconstruction, all of the breasts remained soft, with no clinically detectable fat necrosis or wound-healing problems.

There were 15 complications after surgery (Table 4). Only three cases resulted in reoperation. Two patients had partial skin flap necrosis and subsequently underwent operative debridement and split-thickness skin grafting. Skin grafting served to promote wound healing and, therefore, shortened the time interval between the breast reconstruction and the beginning of postoperative adjuvant therapy. Otherwise, these patients could have healed with only local wound care. Another patient had an area of central abdominal skin slough, requiring a skin graft, after a TRAM flap. Those patients with minor epidermolysis of their native skin flaps were treated conservatively with daily dressing changes and healed without any further problems. Two seromas to the area of the donor site resolved after percutaneous needle aspiration. None of the complications was related to postoperative radiation.


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  		TABLE 4. Complications
 
Local and Distant Recurrence
With an average follow-up time of just longer than 4 years, the local recurrence rate thus far is 4%, and the incidence of distant metastases is 16% overall (Table 3). This compares favorably with local recurrence and distant metastasis rates in the literature for patients with immediate reconstruction (Table 5) or without reconstruction7 after mastectomy. In the one patient with a local recurrence, a skin nodule (<1 cm in diameter) was detected within 3 months after surgery and was successfully treated by local excision followed by radiotherapy.


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  		TABLE 5. Studies evaluating mastectomy with immediate reconstruction for patients with locally advanced breast carcinoma
 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
SSM is becoming more widely used as its use in early-stage breast cancer continues to confirm that local recurrence rates are not increased compared with traditional forms of mastectomy and that the esthetic result is superior to that from other forms of reconstruction. Recent reports documenting the effectiveness of immediate reconstruction after mastectomy for locally advanced disease8 have prompted the use of the skin-sparing technique to evaluate its usefulness. This study is the first to specifically consider immediate breast reconstruction after SSM for locally advanced disease.

Newman et al.8 found no significant differences in local relapse or distant metastasis rates for patients receiving immediate breast reconstruction for locally advanced disease. With the largest series of its kind (50 patients) and the longest median follow-up to date (58.4 months), they have further shown complication rates comparable to those of a similar group of patients who did not undergo immediate breast reconstruction and have shown a delay to postoperative adjuvant therapy that was only marginally significant (35 vs. 21 days; P = .05). The results of our study suggest that SSM with immediate reconstruction is as safe and effective for the treatment of advanced stages of breast carcinoma. Local recurrence and distant metastasis rates are consistent with the study of Newman et al. and other studies of immediate reconstruction after traditional mastectomy for locally advanced breast carcinoma (Table 5).8–11 Despite a low number of well-differentiated tumors, local recurrence rates have remained low. Complications requiring reoperation are relatively few (three patients; 12%). The most significant problem is related to the blood supply of the skin flaps. Partial necrosis may result in the subsequent need for skin grafting. The use of autogenous tissue, though, to fill the skin envelope created by the mastectomy facilitates the healing of ischemic wounds. Postoperative adjuvant therapy is not significantly delayed.

Although median follow-up is only 4 years thus far, most recurrences are detected as palpable skin flap masses within 3 years of the initial cancer diagnosis.5 Because local recurrences typically present as skin nodules, immediate autogenous tissue reconstruction after SSM should not interfere with local tumor surveillance.

Most traditional reconstructive techniques are not well suited for use after SSM. Breast reconstruction, after traditional mastectomy, is typically performed with an expander placed beneath the chest wall muscles or with a flap that supplies skin to recreate the breast mound. Expanders are not necessary after SSM because there is a normal amount of skin and only breast volume to be restored. Implants are not recommended after SSM because the chest wall muscles will not provide adequate coverage. Instead, most patients require autogenous flaps. These flaps supply breast volume and a skin island that needs to be only large enough to recreate the nipple/areola complex. Because the position of the nipple/areola complex is obvious after the flap insetting, nipple reconstruction can be reliably performed at the time of the breast reconstruction. In addition, surgery to the contralateral breast is rarely required because this technique can match the appearance of a ptotic breast so well.

Immediate reconstruction after mastectomy is now widely accepted as safe and effective.12,13 In the past, immediate breast reconstruction was avoided in patients with locally advanced disease because of concerns about poor overall prognosis, the risk of recurrent disease, and the increased risk of complications. In addition, most patients with stage IIB and III disease are treated with chemotherapy before and after surgery and with radiation therapy after surgery; this could potentially lead to problems with wound healing and localized infection and to delays in resumption of adjuvant therapy after surgery. None of these concerns has been substantiated by this study thus far.

This study has generated promising data and should serve to encourage other institutions to consider SSM with immediate reconstruction for patients with locally advanced disease. Patients with locally advanced breast cancer are considered to have a poor prognosis. However, this group of patients has a 50% to 80% 5-year disease-free survival rate.7 With the advent of neoadjuvant therapy, physicians will be increasingly able to judge a patient’s response to treatment, which is highly predictive of survival. The majority of patients have at least a partial response and a reasonable life expectancy. Furthermore, as therapeutic options continue to improve, more women will survive for longer periods of time, and SSMs with immediate reconstruction should be included as an option for women who choose mastectomy.

We organized this study on a prospective basis to address the inherent biases present in a retrospective study. Because of the patient’s desires and body habitus, such a study cannot be randomized. We recognize that our study group is relatively small, and, therefore, it is difficult to draw any final conclusions. However, our database continues to increase and currently has more than 100 patients enrolled. We plan to observe these patients closely long-term. SSM with immediate reconstruction represents a significant achievement for the reconstructive surgeon. Its application to locally advanced breast carcinoma is a significant step toward defining its clinical role.

Received for publication October 4, 2001. Accepted for publication March 9, 2002.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

  1. Toth BA, Lappert P. Modified skin incisions for mastectomy: the need for plastic surgical input in preoperative planning. Plast Reconstr Surg 1991; 87: 1048–53.[Medline]
  2. Simmons RM, Fish SK, Gayle L, et al. Local and distant recurrence rates in skin-sparing mastectomies compared with non-skin-sparing mastectomies. Ann Surg Oncol 1999; 6: 676–81.[Abstract]
  3. Kroll SS, Schusterman MA, Tadjalli HE, et al. Risk of recurrence after treatment of early breast cancer with skin-sparing mastectomy. Ann Surg Oncol 1997; 4: 193–7.[Abstract]
  4. Slavin SA, Schnitt SJ, Duda RB, et al. Skin-sparing mastectomy and immediate reconstruction: oncologic risks and aesthetic results in patients with early-stage breast cancer. Plast Reconstr Surg 1998; 102: 49–62.[Medline]
  5. Newman LA, Kuerer HM, Hunt KK, et al. Presentation, treatment, and outcome of local recurrence after skin-sparing mastectomy and immediate breast reconstruction. Ann Surg Oncol 1998; 5: 620–6.[Abstract]
  6. Carlson GW, Bostwick J, Styblo TM, et al. Skin-sparing mastectomy: oncologic and reconstructive considerations. Ann Surg 1997; 225: 570–5.[CrossRef][Medline]
  7. Carter CL, Allen C, Henson DE. Relation of tumor size, lymph node status, and survival in 24,740 breast cancer cases. Cancer 1989; 63: 181–7.[CrossRef][Medline]
  8. Newman LA, Kuerer HM, Hunt KK, et al. Feasibility of immediate breast reconstruction for locally advanced breast cancer. Ann Surg Oncol 1999; 6: 671–5.[Abstract]
  9. Godfrey PM, Godfrey NV, Romita MC. Immediate autogenous breast reconstruction in clinically advanced disease. Plast Reconstr Surg 1995; 95: 1039–44.[Medline]
  10. Styblo TM, Lewis MM, Carlson GW, et al. Immediate breast reconstruction for stage III breast cancer using transverse rectus abdominis musculocutaneous (TRAM) flap. Ann Surg Oncol 1996; 3: 375–80.[Abstract]
  11. Sultan MR, Smith ML, Estabrook A, et al. Immediate breast reconstruction in patients with locally advanced disease. Ann Plast Surg 1997; 38: 345–9.[Medline]
  12. Kroll SS, Ames F, Singletary SE, et al. The oncologic risks of skin preservation at mastectomy when combined with immediate reconstruction of the breast. Surg Gynecol Obstet 1991; 172: 17–20.
  13. Johnson CH, van Heerden JA, Donohue JH, et al. Oncological aspects of immediate breast reconstruction following mastectomy for malignancy. Arch Surg 1989; 124: 819–23.[Abstract]



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