REVIEW ARTICLE
Making women whole again: A review of breast reconstruction Chrysa Charno, PA-C, MBA; Kristina Marsack, PA-C
ABSTRACT Breast cancer is the second most common type of cancer and the second leading cause of cancer death in American women. Fewer than 25% of women diagnosed with breast cancer are aware of all of their reconstructive options. This article reviews options for breast reconstruction and the team approach that can help women feel whole again after breast cancer surgery. Keywords: breast cancer, reconstruction, implant, free flap, pedicled flap, expander
Breast cancer is the second most common type of cancer cancer, with skin cancer being the most common, and the second leading cause of cancer death in American women, behind lung cancer.1 An estimated 12% of women in the United States (or 1 in 8) will develop invasive breast cancer during their lifetime.1 Breast cancer rates dropped 7% from 2002 to 2003, possibly due to the decline in use of postmenopausal hormonal therapy after publication of the Women’s Health Initiative in 2002, which linked hormone therapy to increased breast cancer risk.1 Increased public awareness, early detection through screening, and improved treatments have reduced the death rate to 3% (1 in 36) over the past 25 years.1 The Women’s Health and Cancer Rights Act (WHCRA), implemented in 1998, requires all insurance companies that offer mastectomy coverage to also provide coverage for certain services related to the mastectomy (restrictions may vary by state).2 These services include all stages of reconstruction for the breast on which the mastectomy was performed (including prosthesis placement) and the necessary reconstructive procedures to the contralateral breast to achieve symmetry.2 All complications of the reconstruction and mastectomy, including proven lymphedema treatments, also must be covered. Additional legislation was passed in 2001 to penalize noncompliant insurers.3 However, according to the American Society Chrysa Charno practices at AccelCare Urgent Care in Rochester, N.Y., and is president of the Association of Plastic Surgery Physician Assistants. Kristina Marsack is an assistant professor in the Department of Plastic and Reconstructive Surgery at Baylor College of Medicine in Houston, Tex., and past president of the Association of Plastic Surgery Physician Assistants. The authors have disclosed no potential conflicts of interest, financial or otherwise.
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ILLUSTRATIONS COURTESY OF THE AMERICAN SOCIETY OF PLASTIC SURGEONS (ASPS)
a
b
c FIGURE 1. Breast reconstruction via free abdominal flap (a)
and pedicled latissimus dorsi flap (b and c). An implant is placed under the flap to add volume. Acknowledgments: The authors would like to thank Shayan Izaddoost, MD, PhD, and Abel Sepulveda, MD, of the Division of Plastic Surgery at Baylor College of Medicine, and Glen Brooks, MD, of Aesthetic Plastic & Reconstructive Surgery in Longmeadow, Mass., for their contributions to this article. DOI: 10.1097/01.JAA.0000453865.47076.8e Copyright © 2014 American Academy of Physician Assistants Volume 27 • Number 10 • October 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
REVIEW ARTICLE TABLE 1.
Breast cancer affects one in eight women in the United States, but less than 25% of patients are aware of all their options for breast reconstruction. Reconstruction performed at the time of mastectomy may be emotionally beneficial to patients, preventing the feeling of breast loss and providing a better cosmetic outcome. Delayed breast reconstruction may be appropriate for patients who need postoperative radiation treatment. Autologous tissue reconstruction may provide the most natural-looking results; use of an abdominal free flap is a popular option.
of Plastic Surgeons (ASPS), less than 25% of women diagnosed with breast cancer are aware of all of their reconstructive options (Table 1). Reimbursement by insurance companies for postmastectomy reconstruction or prosthesis is required by law in 28 states.2 In addition, many states also mandate reimbursement for the contralateral, nondiseased breast to achieve symmetry.2 A 2013 study found that rates of immediate breast reconstruction increased from 20.8% to 37.8% since the passage of WHCRA, which is evidence that with the proper educational tools, both patients and providers can all help to make women feel whole again.4 HISTORICAL REVIEW OF BREAST RECONSTRUCTION Dr. William Halsted, a general surgeon at Johns Hopkins, performed the first radical mastectomy in the United States in 1882; however, breast reconstruction was not attempted until 1895, when a German surgeon transplanted a large lipoma from the patient’s flank for a breast mound. In 1896, Italian surgeon Ignio Tanzini had difficulty closing a large wound from a radical mastectomy, and designed a pedicled (attached to its blood supply) flap of skin and latissimus dorsi muscle that could be rotated to cover the mastectomy defect (Figure 1).5 In the decades that followed, the further development of autologous tissue- and implant-based reconstructions gave patients more options postmastectomy. However, multiple procedures were often required, extending the recovery period after mastectomy from a period of a few months to years. Silicone implants, introduced in 1963, provided increased options for symmetry and projection. Numerous single- and dual-chamber implants have been developed over the years, providing more flexibility in creating the desired breast size and shape (Figure 2). In the late 1970s, for the first time, patients were offered immediate reconstruction at the same time as mastectomy. In these patients, the pedicled latissimus dorsi flap was used in combination with an implant. During the same time period, Dr. Hans Holmstrom reported the first use of discarded tissue from an abdominoplasty for breast recon38
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Breast cancer patient statistics
• 89% of women diagnosed with breast cancer want to see, before undergoing cancer therapy, what reconstructive results look like. • 23% of women diagnosed with breast cancer know the wide range of reconstructive options available to them. • 22% of women diagnosed with breast cancer are familiar with the quality of outcomes that can be expected. • 19% of women understand that the timing of their treatment for breast cancer and the timing of their decision to undergo reconstruction greatly affect their options and results.
struction, and the use of an abdominal-based free tissue transfer (free flap) was born (Figure 1). The world of plastic surgery continued to evolve with the innovative techniques in microsurgical free flap reconstruction, new and safer breast implant options, fat transfer techniques, and increasingly realistic results. IMMEDIATE VS. DELAYED RECONSTRUCTION A patient’s choice of reconstruction depends on many different emotional and physical factors, including current body habitus, cancer staging, history of previous surgeries for donor sites, history of or future need for radiation, and patient preference. Whole breast reconstruction can be divided into two main categories—tissue expander/implant reconstruction and autologous tissue reconstruction. Some patients may even choose a combination of the two, for example with the use of a latissimus dorsi muscle flap and implant. Each procedure has its risks and benefits, both cosmetically and surgically (Table 2).
ILLUSTRATION COURTESY OF THE AMERICAN SOCIETY OF PLASTIC SURGEONS (ASPS)
Key points
FIGURE 2. Loss of breast skin and tissue after mastectomy
(left). A tissue expander is placed under the skin and pectoralis muscle (center). After expansion, the expander is replaced with a saline or silicone implant. Volume 27 • Number 10 • October 2014
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Making women whole again: A review of breast reconstruction
Breast reconstruction can be performed immediately after mastectomy or months to years after the completion of adjuvant cancer therapies. Many surgeons prefer to wait up to a year to perform reconstruction in patients who will require radiation, to let the skin adequately heal from radiation-induced changes, and to reduce the risk of reconstructive failure. The effects of radiation therapy on human tissue, such as contraction and color change, can occur over months to years. Cosmetically, this can be challenging for both the patient and the surgeon. Immediate breast reconstruction can be an emotional benefit to the patient, helping to prevent the feeling of breast loss and asymmetry. Other benefits include fewer further surgical procedures, a shorter total recovery time to reach the final result, and a better cosmetic result because the breast envelope (the mastectomy skin) can be preserved and used immediately for shaping of the new breast mound. The patient must also understand that immediate reconstruction can result in a longer operative time for the mastectomy and reconstruction, often a longer stay in the hospital, and a longer initial recovery period. Delayed breast reconstruction may be more appropriate for patients who are not emotionally prepared to make a decision about the type of reconstruction they would prefer. This option also is appropriate for patients with TABLE 2.
advanced cancer that may require aggressive treatments such as radiation. A disadvantage of delayed reconstruction is that the patient may need to wait a year or more after radiation therapy ends before the reconstructive process can begin. Implant reconstruction is more challenging in these patients because the tissue is difficult to manipulate and expand, increasing the risk of implant complications. For this reason, autologous tissue is the preferred method in delayed reconstruction. TISSUE EXPANDER RECONSTRUCTION Implant-based reconstruction is a common choice for patients due to its many benefits, including a shorter recovery period and symmetry with bilateral reconstruction. The procedure begins with the placement of a tissue expander, a firm temporary implant with an imbedded port. The expander is placed under the skin and pectoralis major muscles to preserve both the natural inframammary fold and protect the device. Mastectomy skin can be very thin, so muscle coverage keeps the implant safe and gives the patient a more natural breast shape during the expansion process, which can take up to 12 weeks. To expand the breast envelope, 0.9% sodium chloride solution is instilled via the port; the resulting tissue expansion makes room for a permanent implant to be placed at a later date.
Benefits and risks of the most common types of breast reconstruction
Method
Benefits
Risks
Tissue expander
• Upper pole fullness
• Requires multiple procedures
• Shorter operative time and recovery period (average 4-6 weeks)
• Implant requires maintenance and possibly replacement
• Symmetry if bilateral breast reconstruction is needed
• Capsular contracture and rupture of implant
• Possibility for increased breast volume if desired
• Rippling of the implant beneath thin mastectomy skin • May not be performed in patients who have had radiation therapy (surgeondependent) • Less-natural aesthetic appearance and feel than using autologous tissue
Autologous tissue
• The most natural type of reconstruction • Provides for great symmetry with a contralateral native breast mound
Latissimus dorsi flap and implant
• Microsurgical risks: Thrombosis and flap loss • Longer operative time
• Tolerates radiation well
• More surgical incisions to heal
• Usually only one major surgery needed
• Longer recovery time (average 6-8 weeks)
• Often needed in patients who have undergone radiation therapy
• Large scar on the donor site
• Provides for nice upper pole fullness
• Prolonged surgical time
• Chronic seroma formation • Recovery can take 4 to 6 weeks
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Placement of this expander can occur at the time of the mastectomy or later in a patient not undergoing radiation therapy. Some surgeons choose to place acellular cadaveric dermis under the skin to increase coverage of the inferior aspect of the expander that allows for increased expansion of the lower pole of the breast mound. Surgery takes 1 to 2 hours in addition to the mastectomy, and the recovery includes an overnight stay in the hospital, followed by weekly visits to the office for expansions until the desired breast shape and size is reached. See Figure 3 for an example of a unilateral silicone implant breast reconstruction. After about 12 weeks, the expander is removed and an implant is placed within the breast pocket in an outpatient procedure. The two basic types of implants are silicone and saline; both come in many different shapes and sizes to match the patient’s breast shape and body habitus. The most common implant used is the smooth round silicone gel, but recently, anatomically shaped form-stable silicone gel implants have been FDA-approved and are gaining popularity. These implants are commonly referred to as “gummy-bear implants,” as their silicone content tends to be more cohesive than previous styles, resulting in a smaller silicone leak in the event of implant rupture.6 Concerns about the perceived higher risk of leakage from silicone implants (compared with saline ones) led the FDA in 1992 to limit the use of silicone implants. Saline implants became more common as numerous women began to blame their silicone implants for the onset of rheumatologic disease and new cancers.7 In 2011, the FDA published an update on the safety of silicone breast implants that stated that no current evidence found an association between the implants and connective tissue disorders, pregnancy, fertility, or difficulty breastfeeding.8 Varying sizes and shapes of the redesigned cohesive silicone gel implants are now available in the United States for reconstructive and cosmetic use. Implant reconstruction does not come without risks and aesthetic downfalls. The major disadvantage is that an implant is a foreign body and the device requires maintenance. Surgical exchange of the device is recommended if the patient has a symptomatic implant complication such as a poor aesthetic result; or develops an infection, rupture, or capsular contracture (a painful scar tissue contracture around the implant). The FDA recommends an MRI be performed at 3 years and then every 2 years thereafter to screen for implant rupture; however, many surgeons reserve this for symptomatic patients and instead rely on clinical examinations and mammograms for surveillance. The reoperation rate for primary reconstruction with silicone implants is 34% in 6 years according to the Mentor Core Study, a continuing industry-sponsored prospective study by one of the breast implant companies.6 Other important factors for patients to consider when choosing implant-based reconstruction are the length of time for completion of the reconstructive process (often 1 40
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REVIEW ARTICLE
FIGURE 3. Right breast reconstruction with tissue expander,
silicone implant, nipple reconstruction, and tattoo
year or more), the need for multiple surgeries, visible wrinkles or rippling, the less-than-natural feel of the prosthetic breast mound, and the increased risk of complications if radiation is required. In 2011, the FDA issued a safety advisory about anaplastic large cell lymphoma (ALCL) in women with breast implants.9 ALCL is a rare type of non-Hodgkin lymphoma and not cancer of the breast tissue. Of the 5 to 10 million women with breast implants, about 60 worldwide have been identified with ALCL.9 The FDA believes that women with breast implants may have a very small but increased risk of developing this disease in the scar capsule adjacent to the implant.9 Providers should be suspicious of persistent seromas that form long after surgical sites are healed, as well as any abnormal lumps, persistent pain, swelling, or asymmetry that develops over time. These patients should be evaluated further with biopsies of tissue and seroma evaluation.10 Confirmed cases of ALCL should be reported to the FDA’s MedWatch program at http:www.fda.gov/ Safety/MedWatch/default.htm. AUTOLOGOUS TISSUE: THE MOST NATURAL RECONSTRUCTED MOUND Using the patient’s own tissue (autologous tissue) for breast reconstruction is becoming increasingly more popular and may provide the most natural aesthetic results. Providing patients with this option has been proven to improve a Volume 27 • Number 10 • October 2014
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patient’s emotional recovery from mastectomy faster than implant-based reconstruction. Plastic surgeons at Memorial Sloan-Kettering Cancer Center have developed the BREASTQ, a questionnaire that is given to patients before and after reconstructive surgery to measure the expectations and satisfaction with their reconstruction. This tool is now used worldwide and has already shown that patients have more long-term satisfaction with autologous tissue breast reconstruction than those with implant-based reconstruction.11 Part of the difference may be due to the aesthetic changes that occur to an implant over time as the body ages around the device, particularly capsular contractures, which may make the implant firm, malpositioned, or painful. Autologous tissue reconstruction can be performed at the time of mastectomy or in a delayed fashion. Recently, women who have had mastectomies many years ago and were never offered reconstruction have been returning for delayed reconstruction. Autologous tissue is also the preferred reconstructive method for patients who have had a lumpectomy with radiation and then develop recurrent cancer requiring a complete mastectomy. Irradiated tissues do not stretch well to accommodate an implant, so patients and surgeons can achieve a better aesthetic result if these tissues are removed and replaced with donor tissue from another part of the body that has not been exposed to radiation therapy (Figure 4). A flap is a piece of tissue composed of skin, fat, a vascular pedicle of one dominant artery and one dominant vein, and sometimes a piece of muscle. For some flaps, muscle needs to be taken along with the blood vessels to ensure perfusion of the transferred tissues because the vessels travel through the muscle fibers. In perforator flaps, the dominant vessels run through the fat itself, and no muscle is needed. In some patients, these perforator flaps are the most beneficial as they pose minimal risk for later hernia development at the donor site. Most commonly, donor tissue used to reconstruct the breast mound is taken from: • the abdomen, creating a transverse rectus abdominus myocutaneous (TRAM) or deep inferior epigastric perforator (DIEP) flap • inner thigh, creating a transverse upper thigh gracilis (TUG) flap • superior buttocks, creating a superior gluteal artery perforator (SGAP) flap • back, creating a latissimus dorsi myocutaneous flap, and frequently used with a tissue expander/implant for increased volume. Pedicled flaps consist of tissue that remains attached to its blood supply; free flaps are tissue that is completely detached from its blood supply, transposed to the wound, and reattached microvascularly. Benefits of autologous tissue include natural feel, natural ptosis (sagging) over time, and symmetry with a contralateral native breast (Figure 5). The cosmetic benJAAPA Journal of the American Academy of Physician Assistants
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Making women whole again: A review of breast reconstruction
FIGURE 4. Delayed breast reconstruction with TRAM flap,
nipple reconstruction with areolar skin graft, and contralateral breast reduction for symmetry
efits of an abdominoplasty type of procedure have driven women to make the TRAM flap reconstruction one of the most popular autologous options to date. See Figure 6 for an example of bilateral DIEP flap breast reconstruction. This procedure does take longer in the OR (anywhere from 3 to 12 hours depending on the type of flap) and requires a few days for recovery in the hospital for tissue monitoring. Thrombosis and flap loss are the most significant complications of microsurgery, requiring close monitoring with a Doppler to check the flap’s blood flow. Loss of a Doppler signal or change in tissue color or temperature may indicate thrombosis and is treated as an emergency requiring immediate surgical exploration of the vascular anastamoses. Long-term complications include scarring at the donor site, development of a hernia or bulge, and possible weakness in the donor site if a muscle flap was used. Although the risks appear to outweigh the benefits, autologous tissue is the preferred method for patients with a larger body habitus because the autologous tissue creates a more natural breast mound and the availability in size and shape of implants can be limited. Patients and providers need to be aware that autologous breast reconstruction in patients who smoke and/or have a BMI of 30 or more poses a significantly increased risk for wound healing complications and overall morbidity.12-14 www.JAAPA.com
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PHOTO COURTESY OF SHAYAN IZADDOOST, MD, PHD
PHOTO COURTESY OF SHAYAN IZADDOOST, MD, PHD
REVIEW ARTICLE
FIGURE 5. Delayed left breast reconstruction after radiation
FIGURE 6. Bilateral immediate breast reconstruction with DIEP
with nipple reconstruction and tattoo
flaps, nipple reconstruction, and tattoo
COMBINING AUTOLOGOUS TISSUE AND AN IMPLANT In thin patients or those who have had radiation in the past and desire implant reconstruction, autologous tissue is often required to maximize tissue expansion and aesthetic outcome. Tissue that has undergone radiation therapy does not expand like native skin, so often the latissimus dorsi flap can be rotated from the patient’s back and moved to the front of the chest wall to form a new breast mound. A
tissue expander, or permanent breast implant, can then be placed beneath this to give the mound increased projection and volume (Figure 7). The use of the latissimus dorsi muscle does not restrict function for most people; patients can still move the arm on the affected side and return to normal activities once healed from surgery. Patients may feel increased weakness performing more aggressive activities such as rock climbing, swimming, or push-ups. Disadvantages of this proce-
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Making women whole again: A review of breast reconstruction
dure include the large scar at the donor site and the risk for prolonged seroma (fluid) collection in the back that requires drainage, in addition to the risks of implant reconstruction previously discussed.
CONCLUSION The world of plastic and reconstructive surgery is changing rapidly as new surgical techniques and devices become available to patients suffering from deforming disease. Patients are no longer required to live without a breast mound and those with reconstruction have many options JAAPA Journal of the American Academy of Physician Assistants
a
b
PHOTO COURTESY OF SHAYAN IZADDOOST, MD, PHD
WHAT’S NEW IN PLASTIC AND RECONSTRUCTIVE SURGERY Fat grafting, or fat injections into the breast, was developed in the 1990s. This technique uses liposuction to harvest fat cells from another part of the body (frequently the abdomen or flanks), remove excess fluid via centrifuge, transfer the viable fat cells into a syringe, and inject them into an area of defect. This has become a very popular technique to minimize rippling around implants, fix a radiation or reconstructive irregularity, or even enhance breast volume patients who do not have cancer and seek breast augmentation for cosmetic reasons. The procedure can be performed on an outpatient basis with minimal recovery time, although there is a risk that some of the fat cells can die, forming an area of firm fat necrosis or calcifications. In theory, these findings could be misdiagnosed as cancer, so a trained radiologist is imperative for patients undergoing mammogram or MRI after reconstruction. Because this procedure is still relatively new, long-term clinical studies have not been conducted to identify the long-term effects and results of fat grafting.15 After reconstructive surgery, many patients are concerned about the appearance of a reconstructed nipple, which can be surgically created with a local tissue flap and a tattooed or skin-grafter areola. Three-dimensional tattooing that creates the appearance of the nipple and areola is increasingly popular among patients who choose to forgo nipple reconstruction. Nipple-sparing mastectomies, which may create the most natural-appearing breast mounds, are gaining popularity and avoid the need for nipple reconstruction. Recent studies have shown that patients who underwent this new type of mastectomy have a higher level of satisfaction with the aesthetic appearance of the breast mound because the native nipple remains, despite the loss of sensation.16 This mastectomy is only safe for selected patients with small, early-stage cancers, and those without a large degree of breast ptosis. Although the risk is low, cancer cells could be left behind in the nipple and mastectomy flaps with skin-sparing techniques, so only select patients with tumors far from the skin and nipple are candidates for this type of mastectomy.17,18 After nipple-sparing mastectomy, reconstruction can be performed with an implant or autologous tissue.
c FIGURE 7. Left breast with periareolar biopsy scar (a). Left breast
reconstruction with latissimus dorsi flap and silicone implant (b). Back donor site scar (c).
for creating natural-looking results. This may often take multiple surgeries to revise a reconstructed breast mound that ages over time with the patient, but satisfaction can be achieved with the right team approach. Both implant and autologous tissue techniques offer patients many benefits, giving women the option to feel whole again after breast cancer. JAAPA www.JAAPA.com
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REFERENCES 1. American Cancer Society. What are the key statistics about breast cancer? http://www.cancer.org/cancer/breastcancer/ detailedguide/breast-cancer-key-statistics. Accessed July 2, 2014. 2. Centers for Disease Control and Prevention, Division of Cancer Prevention and Control. State laws relating to breast cancer. Legislative summary January 1949 to May 2000. http://www. cdc.gov/cancer/breast/pdf/BClaws.pdf. Accessed July 23, 2014. 3. US Department of Labor. Employee Benefits Security Administration. Your rights after a mastectomy: Women’s Health and Cancer Rights Act of 1998 (WHCRA). http://www.dol.gov/ebsa/ publications/whcra.html. Accessed July 2, 2014. 4. Albornoz CR, Bach PB, Mehrara BJ, et al. A paradigm shift in U.S. breast reconstruction: increasing implant rates. Plast Reconstr Surg. 2013;131(1):15-23. 5. Hultman CS, McCraw J. Breast reconstruction with the autogenous latissimus flap: current indications, technique, and outcomes. Breast Dis. 2002;16:65-72. 6. Patient education brochure. Reconstruction. Breast reconstruction with Mentor memory gel silicone gel breast implants. Santa Barbara, CA. Mentor Worldwide LLC. http://www.mentorwwllc. com/Documents/ImportantSafetyInformationReconstruction.pdf. Accessed July 2, 2014. 7. Food and Drug Administration. Regulatory history of breast implants in the U.S. http://www.fda.gov/MedicalDevices/ ProductsandMedicalProcedures/ImplantsandProsthetics/ BreastImplants/ucm064461.htm. Accessed July 2, 2014. 8. FDA Center for Devices and Radiological Health. FDA update on the safety of silicone gel-filled breast implants. June 2011. http:// www.fda.gov/downloads/medicaldevices/productsandmedical procedures/implantsnadprosthetics/breastimplants/UCM260090. pdf. Accessed July 8, 2014. 9. Food and Drug Administration. Anaplastic large cell lymphoma (ALCL). http://www.fda.gov/MedicalDevices/ProductsandMedi-
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10.
11.
12.
13.
14.
15.
16.
17.
18.
calProcedures/ImplantsandProsthetics/BreastImplants/ucm 239995.htm. Accessed July 2, 2014. Kenkel JM. Discussion: anaplastic large cell lymphoma and breast implants: a systematic review. Plast Reconstr Surg. 2011; 127(6):2151-2153. Zhong T, McCarthy C, Min S, et al. Patient satisfaction and health-related quality of life after autologous tissue breast reconstruction: a prospective analysis of early postoperative outcomes. Cancer. 2012;118(6):1701-1709. Spear SL, Ducic I, Cuoco F, Hannan C. The effect of smoking on flap and donor-site complications in pedicled TRAM breast reconstruction. Plast Reconstr Surg. 2005;116(7):1873-1880. Fischer JP, Cleveland EC, Nelson JA, et al. Breast reconstruction in the morbidly obese patient: assessment of 30-day complications using the 2005 to 2010 National Surgical Quality Improvement Program data sets. Plast Reconstr Surg. 2013;132(4): 750-761. Schaverien MV, McCulley SJ. Effect of obesity on outcomes of free autologous breast reconstruction: a meta-analysis. Microsurgery. [e-pub Mar. 20, 2014] Breastcancer.org. Fat grafting. http://www.breastcancer.org/ treatment/surgery/reconstruction/types/autologous/fat-grafting. Accessed July 10, 2014. Djohan R, Gage E, Gatherwright J, et al. Patient satisfaction following nipple-sparing mastectomy and immediate breast reconstruction: an 8-year outcome study. Plast Reconstr Surg. 2010;125(3): 818-829. Spear SL, Willey SC, Feldman ED, et al. Nipple-sparing mastectomy for prophylactic and therapeutic indications. Plast Reconstr Surg. 2011;128(5):1005-1014. Medina-Franco H, Vasconez LO, Fix RJ, et al. Factors associated with local recurrence after skin-sparing mastectomy and immediate breast reconstruction for invasive breast cancer. Ann Surg. 2002;235(6):814-819.
Volume 27 • Number 10 • October 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Making women whole again: A review of breast reconstruction Chrysa Charno, PA-C, MBA; Kristina Marsack, PA-C
ABSTRACT Breast cancer is the second most common type of cancer and the second leading cause of cancer death in American women. Fewer than 25% of women diagnosed with breast cancer are aware of all of their reconstructive options. This article reviews options for breast reconstruction and the team approach that can help women feel whole again after breast cancer surgery. Keywords: breast cancer, reconstruction, implant, free flap, pedicled flap, expander
Breast cancer is the second most common type of cancer cancer, with skin cancer being the most common, and the second leading cause of cancer death in American women, behind lung cancer.1 An estimated 12% of women in the United States (or 1 in 8) will develop invasive breast cancer during their lifetime.1 Breast cancer rates dropped 7% from 2002 to 2003, possibly due to the decline in use of postmenopausal hormonal therapy after publication of the Women’s Health Initiative in 2002, which linked hormone therapy to increased breast cancer risk.1 Increased public awareness, early detection through screening, and improved treatments have reduced the death rate to 3% (1 in 36) over the past 25 years.1 The Women’s Health and Cancer Rights Act (WHCRA), implemented in 1998, requires all insurance companies that offer mastectomy coverage to also provide coverage for certain services related to the mastectomy (restrictions may vary by state).2 These services include all stages of reconstruction for the breast on which the mastectomy was performed (including prosthesis placement) and the necessary reconstructive procedures to the contralateral breast to achieve symmetry.2 All complications of the reconstruction and mastectomy, including proven lymphedema treatments, also must be covered. Additional legislation was passed in 2001 to penalize noncompliant insurers.3 However, according to the American Society Chrysa Charno practices at AccelCare Urgent Care in Rochester, N.Y., and is president of the Association of Plastic Surgery Physician Assistants. Kristina Marsack is an assistant professor in the Department of Plastic and Reconstructive Surgery at Baylor College of Medicine in Houston, Tex., and past president of the Association of Plastic Surgery Physician Assistants. The authors have disclosed no potential conflicts of interest, financial or otherwise.
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ILLUSTRATIONS COURTESY OF THE AMERICAN SOCIETY OF PLASTIC SURGEONS (ASPS)
a
b
c FIGURE 1. Breast reconstruction via free abdominal flap (a)
and pedicled latissimus dorsi flap (b and c). An implant is placed under the flap to add volume. Acknowledgments: The authors would like to thank Shayan Izaddoost, MD, PhD, and Abel Sepulveda, MD, of the Division of Plastic Surgery at Baylor College of Medicine, and Glen Brooks, MD, of Aesthetic Plastic & Reconstructive Surgery in Longmeadow, Mass., for their contributions to this article. DOI: 10.1097/01.JAA.0000453865.47076.8e Copyright © 2014 American Academy of Physician Assistants Volume 27 • Number 10 • October 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
REVIEW ARTICLE TABLE 1.
Breast cancer affects one in eight women in the United States, but less than 25% of patients are aware of all their options for breast reconstruction. Reconstruction performed at the time of mastectomy may be emotionally beneficial to patients, preventing the feeling of breast loss and providing a better cosmetic outcome. Delayed breast reconstruction may be appropriate for patients who need postoperative radiation treatment. Autologous tissue reconstruction may provide the most natural-looking results; use of an abdominal free flap is a popular option.
of Plastic Surgeons (ASPS), less than 25% of women diagnosed with breast cancer are aware of all of their reconstructive options (Table 1). Reimbursement by insurance companies for postmastectomy reconstruction or prosthesis is required by law in 28 states.2 In addition, many states also mandate reimbursement for the contralateral, nondiseased breast to achieve symmetry.2 A 2013 study found that rates of immediate breast reconstruction increased from 20.8% to 37.8% since the passage of WHCRA, which is evidence that with the proper educational tools, both patients and providers can all help to make women feel whole again.4 HISTORICAL REVIEW OF BREAST RECONSTRUCTION Dr. William Halsted, a general surgeon at Johns Hopkins, performed the first radical mastectomy in the United States in 1882; however, breast reconstruction was not attempted until 1895, when a German surgeon transplanted a large lipoma from the patient’s flank for a breast mound. In 1896, Italian surgeon Ignio Tanzini had difficulty closing a large wound from a radical mastectomy, and designed a pedicled (attached to its blood supply) flap of skin and latissimus dorsi muscle that could be rotated to cover the mastectomy defect (Figure 1).5 In the decades that followed, the further development of autologous tissue- and implant-based reconstructions gave patients more options postmastectomy. However, multiple procedures were often required, extending the recovery period after mastectomy from a period of a few months to years. Silicone implants, introduced in 1963, provided increased options for symmetry and projection. Numerous single- and dual-chamber implants have been developed over the years, providing more flexibility in creating the desired breast size and shape (Figure 2). In the late 1970s, for the first time, patients were offered immediate reconstruction at the same time as mastectomy. In these patients, the pedicled latissimus dorsi flap was used in combination with an implant. During the same time period, Dr. Hans Holmstrom reported the first use of discarded tissue from an abdominoplasty for breast recon38
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Breast cancer patient statistics
• 89% of women diagnosed with breast cancer want to see, before undergoing cancer therapy, what reconstructive results look like. • 23% of women diagnosed with breast cancer know the wide range of reconstructive options available to them. • 22% of women diagnosed with breast cancer are familiar with the quality of outcomes that can be expected. • 19% of women understand that the timing of their treatment for breast cancer and the timing of their decision to undergo reconstruction greatly affect their options and results.
struction, and the use of an abdominal-based free tissue transfer (free flap) was born (Figure 1). The world of plastic surgery continued to evolve with the innovative techniques in microsurgical free flap reconstruction, new and safer breast implant options, fat transfer techniques, and increasingly realistic results. IMMEDIATE VS. DELAYED RECONSTRUCTION A patient’s choice of reconstruction depends on many different emotional and physical factors, including current body habitus, cancer staging, history of previous surgeries for donor sites, history of or future need for radiation, and patient preference. Whole breast reconstruction can be divided into two main categories—tissue expander/implant reconstruction and autologous tissue reconstruction. Some patients may even choose a combination of the two, for example with the use of a latissimus dorsi muscle flap and implant. Each procedure has its risks and benefits, both cosmetically and surgically (Table 2).
ILLUSTRATION COURTESY OF THE AMERICAN SOCIETY OF PLASTIC SURGEONS (ASPS)
Key points
FIGURE 2. Loss of breast skin and tissue after mastectomy
(left). A tissue expander is placed under the skin and pectoralis muscle (center). After expansion, the expander is replaced with a saline or silicone implant. Volume 27 • Number 10 • October 2014
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Making women whole again: A review of breast reconstruction
Breast reconstruction can be performed immediately after mastectomy or months to years after the completion of adjuvant cancer therapies. Many surgeons prefer to wait up to a year to perform reconstruction in patients who will require radiation, to let the skin adequately heal from radiation-induced changes, and to reduce the risk of reconstructive failure. The effects of radiation therapy on human tissue, such as contraction and color change, can occur over months to years. Cosmetically, this can be challenging for both the patient and the surgeon. Immediate breast reconstruction can be an emotional benefit to the patient, helping to prevent the feeling of breast loss and asymmetry. Other benefits include fewer further surgical procedures, a shorter total recovery time to reach the final result, and a better cosmetic result because the breast envelope (the mastectomy skin) can be preserved and used immediately for shaping of the new breast mound. The patient must also understand that immediate reconstruction can result in a longer operative time for the mastectomy and reconstruction, often a longer stay in the hospital, and a longer initial recovery period. Delayed breast reconstruction may be more appropriate for patients who are not emotionally prepared to make a decision about the type of reconstruction they would prefer. This option also is appropriate for patients with TABLE 2.
advanced cancer that may require aggressive treatments such as radiation. A disadvantage of delayed reconstruction is that the patient may need to wait a year or more after radiation therapy ends before the reconstructive process can begin. Implant reconstruction is more challenging in these patients because the tissue is difficult to manipulate and expand, increasing the risk of implant complications. For this reason, autologous tissue is the preferred method in delayed reconstruction. TISSUE EXPANDER RECONSTRUCTION Implant-based reconstruction is a common choice for patients due to its many benefits, including a shorter recovery period and symmetry with bilateral reconstruction. The procedure begins with the placement of a tissue expander, a firm temporary implant with an imbedded port. The expander is placed under the skin and pectoralis major muscles to preserve both the natural inframammary fold and protect the device. Mastectomy skin can be very thin, so muscle coverage keeps the implant safe and gives the patient a more natural breast shape during the expansion process, which can take up to 12 weeks. To expand the breast envelope, 0.9% sodium chloride solution is instilled via the port; the resulting tissue expansion makes room for a permanent implant to be placed at a later date.
Benefits and risks of the most common types of breast reconstruction
Method
Benefits
Risks
Tissue expander
• Upper pole fullness
• Requires multiple procedures
• Shorter operative time and recovery period (average 4-6 weeks)
• Implant requires maintenance and possibly replacement
• Symmetry if bilateral breast reconstruction is needed
• Capsular contracture and rupture of implant
• Possibility for increased breast volume if desired
• Rippling of the implant beneath thin mastectomy skin • May not be performed in patients who have had radiation therapy (surgeondependent) • Less-natural aesthetic appearance and feel than using autologous tissue
Autologous tissue
• The most natural type of reconstruction • Provides for great symmetry with a contralateral native breast mound
Latissimus dorsi flap and implant
• Microsurgical risks: Thrombosis and flap loss • Longer operative time
• Tolerates radiation well
• More surgical incisions to heal
• Usually only one major surgery needed
• Longer recovery time (average 6-8 weeks)
• Often needed in patients who have undergone radiation therapy
• Large scar on the donor site
• Provides for nice upper pole fullness
• Prolonged surgical time
• Chronic seroma formation • Recovery can take 4 to 6 weeks
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Placement of this expander can occur at the time of the mastectomy or later in a patient not undergoing radiation therapy. Some surgeons choose to place acellular cadaveric dermis under the skin to increase coverage of the inferior aspect of the expander that allows for increased expansion of the lower pole of the breast mound. Surgery takes 1 to 2 hours in addition to the mastectomy, and the recovery includes an overnight stay in the hospital, followed by weekly visits to the office for expansions until the desired breast shape and size is reached. See Figure 3 for an example of a unilateral silicone implant breast reconstruction. After about 12 weeks, the expander is removed and an implant is placed within the breast pocket in an outpatient procedure. The two basic types of implants are silicone and saline; both come in many different shapes and sizes to match the patient’s breast shape and body habitus. The most common implant used is the smooth round silicone gel, but recently, anatomically shaped form-stable silicone gel implants have been FDA-approved and are gaining popularity. These implants are commonly referred to as “gummy-bear implants,” as their silicone content tends to be more cohesive than previous styles, resulting in a smaller silicone leak in the event of implant rupture.6 Concerns about the perceived higher risk of leakage from silicone implants (compared with saline ones) led the FDA in 1992 to limit the use of silicone implants. Saline implants became more common as numerous women began to blame their silicone implants for the onset of rheumatologic disease and new cancers.7 In 2011, the FDA published an update on the safety of silicone breast implants that stated that no current evidence found an association between the implants and connective tissue disorders, pregnancy, fertility, or difficulty breastfeeding.8 Varying sizes and shapes of the redesigned cohesive silicone gel implants are now available in the United States for reconstructive and cosmetic use. Implant reconstruction does not come without risks and aesthetic downfalls. The major disadvantage is that an implant is a foreign body and the device requires maintenance. Surgical exchange of the device is recommended if the patient has a symptomatic implant complication such as a poor aesthetic result; or develops an infection, rupture, or capsular contracture (a painful scar tissue contracture around the implant). The FDA recommends an MRI be performed at 3 years and then every 2 years thereafter to screen for implant rupture; however, many surgeons reserve this for symptomatic patients and instead rely on clinical examinations and mammograms for surveillance. The reoperation rate for primary reconstruction with silicone implants is 34% in 6 years according to the Mentor Core Study, a continuing industry-sponsored prospective study by one of the breast implant companies.6 Other important factors for patients to consider when choosing implant-based reconstruction are the length of time for completion of the reconstructive process (often 1 40
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FIGURE 3. Right breast reconstruction with tissue expander,
silicone implant, nipple reconstruction, and tattoo
year or more), the need for multiple surgeries, visible wrinkles or rippling, the less-than-natural feel of the prosthetic breast mound, and the increased risk of complications if radiation is required. In 2011, the FDA issued a safety advisory about anaplastic large cell lymphoma (ALCL) in women with breast implants.9 ALCL is a rare type of non-Hodgkin lymphoma and not cancer of the breast tissue. Of the 5 to 10 million women with breast implants, about 60 worldwide have been identified with ALCL.9 The FDA believes that women with breast implants may have a very small but increased risk of developing this disease in the scar capsule adjacent to the implant.9 Providers should be suspicious of persistent seromas that form long after surgical sites are healed, as well as any abnormal lumps, persistent pain, swelling, or asymmetry that develops over time. These patients should be evaluated further with biopsies of tissue and seroma evaluation.10 Confirmed cases of ALCL should be reported to the FDA’s MedWatch program at http:www.fda.gov/ Safety/MedWatch/default.htm. AUTOLOGOUS TISSUE: THE MOST NATURAL RECONSTRUCTED MOUND Using the patient’s own tissue (autologous tissue) for breast reconstruction is becoming increasingly more popular and may provide the most natural aesthetic results. Providing patients with this option has been proven to improve a Volume 27 • Number 10 • October 2014
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patient’s emotional recovery from mastectomy faster than implant-based reconstruction. Plastic surgeons at Memorial Sloan-Kettering Cancer Center have developed the BREASTQ, a questionnaire that is given to patients before and after reconstructive surgery to measure the expectations and satisfaction with their reconstruction. This tool is now used worldwide and has already shown that patients have more long-term satisfaction with autologous tissue breast reconstruction than those with implant-based reconstruction.11 Part of the difference may be due to the aesthetic changes that occur to an implant over time as the body ages around the device, particularly capsular contractures, which may make the implant firm, malpositioned, or painful. Autologous tissue reconstruction can be performed at the time of mastectomy or in a delayed fashion. Recently, women who have had mastectomies many years ago and were never offered reconstruction have been returning for delayed reconstruction. Autologous tissue is also the preferred reconstructive method for patients who have had a lumpectomy with radiation and then develop recurrent cancer requiring a complete mastectomy. Irradiated tissues do not stretch well to accommodate an implant, so patients and surgeons can achieve a better aesthetic result if these tissues are removed and replaced with donor tissue from another part of the body that has not been exposed to radiation therapy (Figure 4). A flap is a piece of tissue composed of skin, fat, a vascular pedicle of one dominant artery and one dominant vein, and sometimes a piece of muscle. For some flaps, muscle needs to be taken along with the blood vessels to ensure perfusion of the transferred tissues because the vessels travel through the muscle fibers. In perforator flaps, the dominant vessels run through the fat itself, and no muscle is needed. In some patients, these perforator flaps are the most beneficial as they pose minimal risk for later hernia development at the donor site. Most commonly, donor tissue used to reconstruct the breast mound is taken from: • the abdomen, creating a transverse rectus abdominus myocutaneous (TRAM) or deep inferior epigastric perforator (DIEP) flap • inner thigh, creating a transverse upper thigh gracilis (TUG) flap • superior buttocks, creating a superior gluteal artery perforator (SGAP) flap • back, creating a latissimus dorsi myocutaneous flap, and frequently used with a tissue expander/implant for increased volume. Pedicled flaps consist of tissue that remains attached to its blood supply; free flaps are tissue that is completely detached from its blood supply, transposed to the wound, and reattached microvascularly. Benefits of autologous tissue include natural feel, natural ptosis (sagging) over time, and symmetry with a contralateral native breast (Figure 5). The cosmetic benJAAPA Journal of the American Academy of Physician Assistants
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Making women whole again: A review of breast reconstruction
FIGURE 4. Delayed breast reconstruction with TRAM flap,
nipple reconstruction with areolar skin graft, and contralateral breast reduction for symmetry
efits of an abdominoplasty type of procedure have driven women to make the TRAM flap reconstruction one of the most popular autologous options to date. See Figure 6 for an example of bilateral DIEP flap breast reconstruction. This procedure does take longer in the OR (anywhere from 3 to 12 hours depending on the type of flap) and requires a few days for recovery in the hospital for tissue monitoring. Thrombosis and flap loss are the most significant complications of microsurgery, requiring close monitoring with a Doppler to check the flap’s blood flow. Loss of a Doppler signal or change in tissue color or temperature may indicate thrombosis and is treated as an emergency requiring immediate surgical exploration of the vascular anastamoses. Long-term complications include scarring at the donor site, development of a hernia or bulge, and possible weakness in the donor site if a muscle flap was used. Although the risks appear to outweigh the benefits, autologous tissue is the preferred method for patients with a larger body habitus because the autologous tissue creates a more natural breast mound and the availability in size and shape of implants can be limited. Patients and providers need to be aware that autologous breast reconstruction in patients who smoke and/or have a BMI of 30 or more poses a significantly increased risk for wound healing complications and overall morbidity.12-14 www.JAAPA.com
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FIGURE 5. Delayed left breast reconstruction after radiation
FIGURE 6. Bilateral immediate breast reconstruction with DIEP
with nipple reconstruction and tattoo
flaps, nipple reconstruction, and tattoo
COMBINING AUTOLOGOUS TISSUE AND AN IMPLANT In thin patients or those who have had radiation in the past and desire implant reconstruction, autologous tissue is often required to maximize tissue expansion and aesthetic outcome. Tissue that has undergone radiation therapy does not expand like native skin, so often the latissimus dorsi flap can be rotated from the patient’s back and moved to the front of the chest wall to form a new breast mound. A
tissue expander, or permanent breast implant, can then be placed beneath this to give the mound increased projection and volume (Figure 7). The use of the latissimus dorsi muscle does not restrict function for most people; patients can still move the arm on the affected side and return to normal activities once healed from surgery. Patients may feel increased weakness performing more aggressive activities such as rock climbing, swimming, or push-ups. Disadvantages of this proce-
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Making women whole again: A review of breast reconstruction
dure include the large scar at the donor site and the risk for prolonged seroma (fluid) collection in the back that requires drainage, in addition to the risks of implant reconstruction previously discussed.
CONCLUSION The world of plastic and reconstructive surgery is changing rapidly as new surgical techniques and devices become available to patients suffering from deforming disease. Patients are no longer required to live without a breast mound and those with reconstruction have many options JAAPA Journal of the American Academy of Physician Assistants
a
b
PHOTO COURTESY OF SHAYAN IZADDOOST, MD, PHD
WHAT’S NEW IN PLASTIC AND RECONSTRUCTIVE SURGERY Fat grafting, or fat injections into the breast, was developed in the 1990s. This technique uses liposuction to harvest fat cells from another part of the body (frequently the abdomen or flanks), remove excess fluid via centrifuge, transfer the viable fat cells into a syringe, and inject them into an area of defect. This has become a very popular technique to minimize rippling around implants, fix a radiation or reconstructive irregularity, or even enhance breast volume patients who do not have cancer and seek breast augmentation for cosmetic reasons. The procedure can be performed on an outpatient basis with minimal recovery time, although there is a risk that some of the fat cells can die, forming an area of firm fat necrosis or calcifications. In theory, these findings could be misdiagnosed as cancer, so a trained radiologist is imperative for patients undergoing mammogram or MRI after reconstruction. Because this procedure is still relatively new, long-term clinical studies have not been conducted to identify the long-term effects and results of fat grafting.15 After reconstructive surgery, many patients are concerned about the appearance of a reconstructed nipple, which can be surgically created with a local tissue flap and a tattooed or skin-grafter areola. Three-dimensional tattooing that creates the appearance of the nipple and areola is increasingly popular among patients who choose to forgo nipple reconstruction. Nipple-sparing mastectomies, which may create the most natural-appearing breast mounds, are gaining popularity and avoid the need for nipple reconstruction. Recent studies have shown that patients who underwent this new type of mastectomy have a higher level of satisfaction with the aesthetic appearance of the breast mound because the native nipple remains, despite the loss of sensation.16 This mastectomy is only safe for selected patients with small, early-stage cancers, and those without a large degree of breast ptosis. Although the risk is low, cancer cells could be left behind in the nipple and mastectomy flaps with skin-sparing techniques, so only select patients with tumors far from the skin and nipple are candidates for this type of mastectomy.17,18 After nipple-sparing mastectomy, reconstruction can be performed with an implant or autologous tissue.
c FIGURE 7. Left breast with periareolar biopsy scar (a). Left breast
reconstruction with latissimus dorsi flap and silicone implant (b). Back donor site scar (c).
for creating natural-looking results. This may often take multiple surgeries to revise a reconstructed breast mound that ages over time with the patient, but satisfaction can be achieved with the right team approach. Both implant and autologous tissue techniques offer patients many benefits, giving women the option to feel whole again after breast cancer. JAAPA www.JAAPA.com
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REFERENCES 1. American Cancer Society. What are the key statistics about breast cancer? http://www.cancer.org/cancer/breastcancer/ detailedguide/breast-cancer-key-statistics. Accessed July 2, 2014. 2. Centers for Disease Control and Prevention, Division of Cancer Prevention and Control. State laws relating to breast cancer. Legislative summary January 1949 to May 2000. http://www. cdc.gov/cancer/breast/pdf/BClaws.pdf. Accessed July 23, 2014. 3. US Department of Labor. Employee Benefits Security Administration. Your rights after a mastectomy: Women’s Health and Cancer Rights Act of 1998 (WHCRA). http://www.dol.gov/ebsa/ publications/whcra.html. Accessed July 2, 2014. 4. Albornoz CR, Bach PB, Mehrara BJ, et al. A paradigm shift in U.S. breast reconstruction: increasing implant rates. Plast Reconstr Surg. 2013;131(1):15-23. 5. Hultman CS, McCraw J. Breast reconstruction with the autogenous latissimus flap: current indications, technique, and outcomes. Breast Dis. 2002;16:65-72. 6. Patient education brochure. Reconstruction. Breast reconstruction with Mentor memory gel silicone gel breast implants. Santa Barbara, CA. Mentor Worldwide LLC. http://www.mentorwwllc. com/Documents/ImportantSafetyInformationReconstruction.pdf. Accessed July 2, 2014. 7. Food and Drug Administration. Regulatory history of breast implants in the U.S. http://www.fda.gov/MedicalDevices/ ProductsandMedicalProcedures/ImplantsandProsthetics/ BreastImplants/ucm064461.htm. Accessed July 2, 2014. 8. FDA Center for Devices and Radiological Health. FDA update on the safety of silicone gel-filled breast implants. June 2011. http:// www.fda.gov/downloads/medicaldevices/productsandmedical procedures/implantsnadprosthetics/breastimplants/UCM260090. pdf. Accessed July 8, 2014. 9. Food and Drug Administration. Anaplastic large cell lymphoma (ALCL). http://www.fda.gov/MedicalDevices/ProductsandMedi-
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10.
11.
12.
13.
14.
15.
16.
17.
18.
calProcedures/ImplantsandProsthetics/BreastImplants/ucm 239995.htm. Accessed July 2, 2014. Kenkel JM. Discussion: anaplastic large cell lymphoma and breast implants: a systematic review. Plast Reconstr Surg. 2011; 127(6):2151-2153. Zhong T, McCarthy C, Min S, et al. Patient satisfaction and health-related quality of life after autologous tissue breast reconstruction: a prospective analysis of early postoperative outcomes. Cancer. 2012;118(6):1701-1709. Spear SL, Ducic I, Cuoco F, Hannan C. The effect of smoking on flap and donor-site complications in pedicled TRAM breast reconstruction. Plast Reconstr Surg. 2005;116(7):1873-1880. Fischer JP, Cleveland EC, Nelson JA, et al. Breast reconstruction in the morbidly obese patient: assessment of 30-day complications using the 2005 to 2010 National Surgical Quality Improvement Program data sets. Plast Reconstr Surg. 2013;132(4): 750-761. Schaverien MV, McCulley SJ. Effect of obesity on outcomes of free autologous breast reconstruction: a meta-analysis. Microsurgery. [e-pub Mar. 20, 2014] Breastcancer.org. Fat grafting. http://www.breastcancer.org/ treatment/surgery/reconstruction/types/autologous/fat-grafting. Accessed July 10, 2014. Djohan R, Gage E, Gatherwright J, et al. Patient satisfaction following nipple-sparing mastectomy and immediate breast reconstruction: an 8-year outcome study. Plast Reconstr Surg. 2010;125(3): 818-829. Spear SL, Willey SC, Feldman ED, et al. Nipple-sparing mastectomy for prophylactic and therapeutic indications. Plast Reconstr Surg. 2011;128(5):1005-1014. Medina-Franco H, Vasconez LO, Fix RJ, et al. Factors associated with local recurrence after skin-sparing mastectomy and immediate breast reconstruction for invasive breast cancer. Ann Surg. 2002;235(6):814-819.
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