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ScienceDirect EJSO 40 (2014) 442e448


Skin reducing mastectomy and immediate reconstruction: The effect of radiotherapy on complications and patient reported outcomes V. Korwar*, J. Skillman a, P. Matey a Department of Breast Surgery, The Royal Wolverhampton Hospitals NHS Trust, New Cross Hospital, Wednesfield Road, Wolverhampton WV10 0QP, UK Accepted 4 January 2014 Available online 22 January 2014

Abstract Aim: Skin reducing mastectomy, dermal sling and immediate implant reconstruction (SRMIR) is an emerging technique where, deepithelialised inferior skin flap sutured to pectoralis major provides vascularised, dermal sling for the implant. We aimed to assess patient satisfaction following SRMIR and determine if radiotherapy affected patient reported outcomes. Method: A prospective database of women undergoing SRMIR was analysed. SRMIR was performed in 92 women (116 breasts). Radiotherapy was received by 45 women and it was not required in 47 women. Forty eight women had contralateral surgery: 21 breast reduction/ mastopexy, 1 augmentation, 26 mastectomy/reconstruction. A validated breast evaluation questionnaire provided patient reported outcomes. Results: Median follow up was 20 months. Early complications were similar in both groups, but those in the radiotherapy group had a higher incidence of implant loss (6/45 ¼ 13% vs 1/47 ¼ 2%; p ¼ 0.06) and grade III/IV capsular contracture (11/45 ¼ 24% vs 6/ 47 ¼ 13%; p ¼ 0.20). The outcome questionnaire was sent to 83 women who were disease free and had retained their implants. Sixty three women responded (76%). Patient reported satisfaction was high, with or without radiotherapy. Women receiving radiotherapy gave lower scores, but it was statistically significant only for general appearance and symmetry. Conclusions: Although complications after radiotherapy are higher in patients who had SRMIR, the majority of women who retained their implant are highly satisfied with their reconstruction. Majority of these patients were happy to recommend SRMIR procedure to their friend. Ó 2014 Elsevier Ltd. All rights reserved. Keywords: Skin reducing mastectomy; Breast cancer; Breast reconstruction; Breast implant; Radiotherapy; Dermal sling; Single stage breast reconstruction

Introduction Skin reducing mastectomy, dermal sling and immediate subpectoral implant breast reconstruction is a relatively new technique in breast surgery, which makes use of the inferior breast skin as a sling to provide the lower part of the implant a completely vascularised internal pocket. If adequate ptosis exists or contralateral symmetrising surgery is chosen, the reconstruction can be completed in a single stage. Alternatively, expander prosthesis can be used to achieve symmetry. Patient reported satisfaction with SRMIR has been published in few studies with small * Corresponding author. Tel.: þ44 1902695978; fax: þ44 1902695754. E-mail address: [email protected] (V. Korwar). a Tel.: þ44 1902695978; fax: þ44 1902695754. 0748-7983/$ - see front matter Ó 2014 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ejso.2014.01.003

number of patients and short follow up, but comparison of outcomes with and without radiotherapy has been lacking in the literature. Radiotherapy is offered to women following mastectomy for node positive or higher risk breast cancer to decrease their risk of local recurrence.1,2 Radiotherapy adversely affects the outcomes from breast reconstruction (particularly with implants) by increasing the risks of infection, capsular contracture and a poor cosmetic result.3,4 Delayed reconstruction or autologous immediate reconstruction can be offered if radiotherapy is highly likely. Although the results of autologous breast reconstruction are better, many women are unsuitable or unwilling to have these surgeries and prefer an immediate, single stage procedure. Moreover, delayed implant reconstruction is

V. Korwar et al. / EJSO 40 (2014) 442e448

even more difficult after radiotherapy such that many women, who are unsuitable for autologous reconstruction, may be refused any sort of reconstruction. Immediate implant based reconstruction allows preservation of the skin envelope and does not preclude later autologous reconstruction. In some cases patients have chosen an immediate/delayed approach: an implant is placed at the time of skin reducing mastectomy to preserve the skin envelope and subsequent definitive, autologous reconstruction can be achieved after completion of adjuvant treatment. Aim The primary aim of this study was to investigate whether women were satisfied following skin reducing mastectomy and immediate subpectoral implant/expander based reconstruction. Secondary aims were to study whether outcomes were affected by radiotherapy: early and medium term complications, in particular implant loss and capsular contracture and the patients’ satisfaction with cosmetic and functional outcome. Knowledge of these outcomes will allow clinicians to provide women who are not candidates for autologous options to be informed of the risks and benefits of SRMIR. Method This study was carried out at a single breast surgery unit at Newcross Hospital in West Midlands, UK. The unit receives tertiary referrals from neighbouring units, which do not have facilities for reconstruction. The senior author prospectively collected information for a database of women undergoing surgery for breast cancer. This database was used to identify those women who chose skin reducing mastectomy and immediate breast reconstruction with the dermal sling technique. Every consecutive patient was included between 2006 and 2011. Their hospital records were searched for demographic data, details of breast cancer size and nodal involvement. We recorded date and type of surgery, contralateral surgery, early and late complications, details of radiotherapy or chemotherapy and length of follow up (Table 1). Surgical procedures for symmetry and additional procedures, such as lipomodelling or revision surgery were documented. No patients were excluded from this data collection, which was undertaken retrospectively. All procedures were carried out by a single surgeon. Surgical technique Preoperative markings were made with the patient in sitting position. A standard ‘wise’ pattern was used, with a triangular excision of the nipple and medial and lateral extensions. The mastectomy was performed through these incisions. The inferior skin, adjacent to the inframammary fold (IMF) was not discarded. Instead, it was left attached


Table 1 Patient demographics and procedures.

Total women Mean age (years) Mean BMI Smokers Previous contralateral surgery Mean tumour size [in mm] Total SRM [Breasts] Contralateral mastopexy/reduction/ augmentation Immediate/delayed approach Follow up [median] months Total questionnaires senta Total questionnaire completed

Radiotherapy (RT)

No radiotherapy (NRT)

45 49.5 27.3 7 1 (LD) 48 57 11

47 52.1 27.2 6 1 (LD) 28 59 11

7 23 37 26 (70%)

4 18 46 37 (80%)

BMI- Body Mass Index, LD- Latissimus Dorsi flap, SRM- Skin Reducing Mastectomy. a Exclusions for questionnaire included implant loss and metastatic disease.

along the whole length of the IMF and de-epithelialised. The superior medial and lateral skin flaps, which would be redraped to make the medial and lateral skin of the breast, were incised along their lower edge so that three flaps were created in total: medial skin flap, lateral skin flap and inferior de-epithelialised flap.6 The pectoralis muscle was raised in the usual way and the implant or expander was placed beneath the muscle. The de-epithelialised skin was sutured to the lower border of the pectoralis major and in this way provided a completely vascularised pocket for the implant/expander (IE). The medial and lateral skin was then re-draped over the new breast mound and skin closed as an inverted T, as usual for a wise pattern breast reduction. If the breast was ptotic, the redundant skin was sufficient to accommodate an implant of similar volume to the remaining breast, and volume symmetry was satisfactory after a single operation. Shape symmetry was improved in women with larger breasts, if the woman requested a simultaneous contralateral Mastopexy (Fig. 1). Nipple reconstruction and tattooing was performed as second stage procedure under local anaesthetic. A total of 92 women choosing skin reducing mastectomy and immediate implant based reconstruction were identified. If a woman had sufficient ptosis, the breast skin could be redistributed to create a large enough pocket for a fixed volume implant at the primary operation. If the breast was small, or contralateral surgery was not chosen, an implant/IE (McGhan style 150, Inamed Aesthetics, Ireland) was inserted to allow expansion after completion of radiotherapy and adjustment of size at a later date as required. The patient was fully consented for the procedure and the possibility of poor outcome requiring revision of surgery was fully discussed. An immediate/delayed approach was chosen by 11 women, who requested a DIEP flap (Deep Inferior Epigastric Perforator) at the outset, but preferred to delay the


V. Korwar et al. / EJSO 40 (2014) 442e448

given to 6 women who had recurrent breast cancer after previous breast conserving surgery, and 1 who had previously been given mantel radiotherapy for lymphoma. Adjuvant radiotherapy was given to the remaining 38 women in this group (Fig 2). In RT group 37/45 patients had infiltrating ductal, 6 lobular carcinoma and 2 patients had high grade ductal carcinoma in situ. NRT group comprised of 7 risk reducing mastectomies, out of remaining (n ¼ 40) 18 patients had infiltrating ductal, 5 lobular, 2 tubular, 1 mucinous carcinoma and 14 ductal carcinoma in situ. Chemotherapy was given to 34 patients in RT group compared to12 in NRT group. Demographics such as mean BMI, age and current smoking habits were similar in both groups (Table 1). Figure 1. Postoperative appearance in a patient who was not given radiotherapy after Lt. SRMIR & Rt. Mastopexy.

Complications autologous reconstruction until after completion of adjuvant therapy. In these cases an immediate reconstruction with an expander was done. This combination of techniques allowed preservation of the breast skin envelope and avoidance of radiotherapy effects on autologous reconstruction. However, some patients who requested the immediate/delayed approach are satisfied with their initial reconstruction and have not proceeded to have their ‘definitive’ procedure. All appropriate patients were sent a validated questionnaire with supplementary questions relevant to this study.7 Exclusions for sending a questionnaire included, women who had lost their implants (n ¼ 7) and those diagnosed with systemic metastasis (n ¼ 6). Outcomes were scored by the women on a scale of 1e5, where 1 is poor and 5 is excellent. Satisfaction was recorded for the SRMIR side in women who had bilateral surgery. The SRMIR breast was rated separately for size, shape, firmness of the reconstruction in different situations: professional, social and intimate. Mean scores for these three aspects of the breast were calculated for both the radiotherapy and no radiotherapy groups, in each situation and their results compared. The postoperative scoring was broadly divided into situations (professional, Social & intimate), general appearance, appearance of the breasts, symmetry and overall score for both breasts. Statistical analysis was performed. Total score in each broad category was tabulated for NRT (no radiotherapy) and RT (radiotherapy) groups. A ManneWhitney test was applied to combined score in each category. Complications like implant loss and capsular contracture were entered into contingency table. A Fisher’s exact test was applied to this data.

Early complications were at similar rates in both groups. Overall complications in RT group were 13 and in NRT 17 (Table 2). In the RT group 6/45 (13%) implants were lost whereas only 1/47 (2%) implant was lost in NRT group ( p ¼ 0.06). There was only 1 early (within 3 months) implant loss in NRT group which was removed after aspiration of infected seroma and later salvaged by deep inferior epigastric perforator flap. The majority of implant extrusion occurred 6 months after surgery, after the completion of radiotherapy (n ¼ 3). One patient had delayed implant loss (RT group) after 2 years due to implant exposure. Three implants were lost amongst the women who had preoperative radiotherapy. Infected seroma was the cause of implant loss in 4/6 in RT and 1/1 in NRT groups, whereas 1 patient in RT group lost implant due to lateral skin necrosis after 4 months, which was salvaged using latissimus dorsi flap. In this series where 7 implants were lost, 3/7 patients were smokers, 1 diabetic, 6 (RT group) had chemotherapy (3 neoadjuvant & 3 adjuvant) and median BMI was 29.5. Baker’s classification was used to classify capsular contracture for all breast reconstructions before lipomodelling was offered. Grade III and IV capsular contracture rates were

Results Over a period of four years, 92 women (116 breasts) underwent skin reducing mastectomy and immediate implant/ implant expander breast reconstruction. Forty seven women did not have radiotherapy. Forty five women had radiotherapy before or after SRMIR. Radiotherapy had been

Figure 2. Appearance after bilateral SRMIR and radiotherapy.

V. Korwar et al. / EJSO 40 (2014) 442e448 Table 2 Complications after SRMIR in two groups.

Early implant loss (in first 3 months) Late implant loss (3e12 months) Delayed implant loss (>1 year) T junction necrosis Haematoma Seroma Infection Fat necrosis Capsular contracture


Table 3 Patient scores for SRMIR in RT and NRT groups.

Radiotherapy (RT)

No radiotherapy (NRT)


1 (had DIEP)

5 (1 had LDF, 1 DIEP)




3 3 5 2 0 11 (9 had lipomodelling, 3 considering DIEP)

3 5 7 0 1 6 (3 had lipomodelling)

LDF- Latissimus Dorsi Flap, DIEP- Deep Inferior Epigastric Perforator flap.

higher in the radiotherapy compared to the non radiotherapy group. There are 11/45 (24%) capsular contractures in RT compared to 6/47 (13%) in NRT group ( p ¼ 0.20). Though the number of implant loss and capsular contracture is higher in RT group, using Fisher’s exact test we found no statistically significant difference between the two groups. Outcome questionnaires The outcome questionnaire was sent to 83 women who had retained their implants and had no evidence of breast cancer recurrence. Sixty six women responded but three women in the radiotherapy group sent back the questionnaires uncompleted as they felt it was too early to give an opinion (Total response rate 76%). Reported satisfaction was high, with or without radiotherapy, particularly in professional and social situations (Table 3). Women who had received radiotherapy gave lower scores for symmetry and satisfaction with their breast in general appearance. We used ManneWhitney test to analyse the statistical significance in the score between RT and NRT groups. The mean scores in NRT group were higher compared to RT group, but it was statistically significant only in general appearance ( p ¼ 0.02) and symmetry of the breasts ( p ¼ 0.003). The best discriminator between the two groups’ outcomes was satisfaction with symmetry. Overall the patient reported outcomes show promising initial results in terms of aesthetic outcome and patient satisfaction. SRMIR satisfies 90% of women 99% would recommend breast reconstruction to a friend. Immediate SRMIR can provide satisfactory reconstruction regardless of radiotherapy, in the short term. Longer term follow up of this cohort of women is planned. Discussion Immediate implant based breast reconstruction is gaining popularity especially in women who are not suitable

Professional situation Social situation Intimate situation General appearance Appearance of breasts Symmetry Overall score Pts recommending the procedure

NRT [mean score]

RT [mean score]

P value [ManneWhitney test, two tailed]

4.63 4.58 3.88 4.08 4.06 3.58 4.03 37/37

4.18 3.96 3.32 3.35 3.50 2.60 3.71 25/26

0.16 0.15 0.16 0.02* 0.06 0.003* 0.39

NRT- no radiotherapy, RT- Radiotherapy. * Bold values indicate statistically significant difference in scores.

or who do not want autologous reconstruction.8 Immediate breast reconstruction has the advantage of single operation and anaesthetic, ease of working with more natural tissues, decreased psychological morbidity to the patients and reduced cost of treatment.9,10 Newer mastectomy techniques with increased coverage of the implant may reduce implant palpability and capsular contracture. Skin sparing mastectomy can easily be performed through periareolar approach in case of small breasts. Medium and large sized breasts require an amount of skin reduction and contralateral symmetrisation for best cosmetic outcome. Total submuscular coverage has the advantages of total implant coverage but the disadvantage of increased dissection and sometimes results in a high implant. Acellular dermal matrix (Strattice Ô) reconstruction is expensive but a good alternative in women who have minimal ptosis. Studies have shown using acellular dermal matrix to cover inferolateral aspect of implant allows less muscle dissection, better cosmetic outcome and less pronounced effects of radiation, but the evidence is not strong and others believe it is associated with increased rate of complications.11 The dermal sling technique SRMIR6 in which the breast skin is redistributed to allow a dual layer closure, has the advantages of single stage reconstruction, with natural ptosis. Nava et al. have explained the selection criteria for SRMIR which include: Nipple to sternal notch distance of 8 cm, length of vertical limbs 5e7 cm plus 2 cm for nipple, depending on amount of reduction. Earlier studies on skin reducing mastectomy have reported high complication rate at ‘T’ junction,12,13 but recent studies by Nava et al. reported 6/30 epidermolysis, 4/30 implant extrusion. In our series, we had 6/116 ‘T’ junction necrosis. Post mastectomy radiation has been shown to improve loco regional disease control and disease free survival in patients with invasive breast cancer.1,2 As a result radiotherapy is being increasingly used in the treatment of breast cancer. One of the major negative effects of radiation is increased incidence of capsular contracture leading to poor cosmetic outcome, increased reoperation rate and


V. Korwar et al. / EJSO 40 (2014) 442e448

loss of breast reconstruction.14 In case of implant or implant expander reconstructions, studies have demonstrated that there is increased fibroproliferation through wingless signalling pathway contributing towards increased incidence of capsular contracture.15 To avoid the negative effects of radiation, Kronowitz et al.5 recommended a delayed- immediate approach, where an implant expander is inserted as temporary immediate reconstruction which is soon converted to permanent reconstruction if no postoperative radiotherapy is required or a delayed exchange to implant is planned if radiotherapy is required. Nava et al.16 conducted a non randomised study to compare the effects of radiation to a two stage breast reconstruction when radiation to chest wall is given during IE expansion phase or after exchanging IE to implant. They found higher failure rates if radiotherapy is given during expansion phase. Table 4 provides a summary of results of selected recent studies where immediate implant reconstruction (excluding implant with alloderm or autologous reconstructions) was performed with or without post mastectomy radiotherapy. From the table, the rate of implant loss varies from 7 to 37% in patients who had radiotherapy and 2e13% who did not receive radiotherapy. It is evident from the studies that, common causes of implant loss are infection, skin necrosis and severe capsular contracture and these changes are more common after radiotherapy. Few studies have found no significant difference in postoperative complications and explantation rate between the two groups.25,29,19,23 The overall complication rate in our study has been higher in radiotherapy group compared to non radiotherapy group, but it was not statistically significant and less than the reported complication rate in NMBRA.30 UK National

mastectomy and breast reconstruction audit (NMBRA) of over 18,000 cases in which the rate of implant loss in immediate implant based reconstruction was 9% within 3 months of surgery. Most of our implant losses were later than this time period so even 13% of implant losses in 2 years after surgery in the radiotherapy group compares well with the 9% at 3 months recorded in NMBRA. In the NRT group implant loss was 2%. Incidence of capsular contracture after implant based breast reconstruction has been reported varying widely in the literature from 0 to 40% in patients who did not receive RT and 17e68% in patients who had RT. Radiotherapy increases the incidence of severe capsular contracture and it is more obvious from the studies with longer follow up. In our study the incidence was 24.4% in RT group and 12.7% in NRT group. We have used lipomodelling to improve the capsular contracture in selected patients from these two groups and observed better results in NRT group. The patient acceptance for this form of reconstruction has been very good with high satisfaction rates. Other studies have reported similar early outcomes. Cordeiro et al.28 studied immediate breast reconstructions using TE (Tissue Expander) or implant divided into RT and NRT groups. Aesthetic outcome was assessed using a self assessment questionnaire (details not mentioned) and they found higher patient reported aesthetic outcome and satisfaction in NRT group compared to RT group. There was a statistically significant difference in patient satisfaction between RT and NRT groups, but not the outcome. Goyal et al.29 reported high patient satisfaction using BREAST-Q score in 28 implant based immediate reconstructions after dermal sling skin reducing mastectomy. In their series 3/28 patients had radiotherapy and median follow up was 21 months.

Table 4 Summary of some recent studies involving Implant based breast reconstruction. Author

No of reconstruction


Follow up


Implant loss

Capsular contracture


24.1 m 29 m 3.7 y 40.2 m 16 m 15 m 6w 32.4 m 37 m 13.6 m 25 m

20% NR (26) 13% (7/97) 7.2% 15% (1/62) 1.6% 6% 15.25% 22.7% (4/30)13.3% RT ¼ 24% NRT ¼ 9% RT 7/19 ¼ 37% NRT 5/62 ¼ 8% RT ¼ 11% NRT ¼ 6% 0%

NR 4% NR 24.9% NR 8.5% NR 11.25% 32.5% 0% RT ¼ 11% NRT ¼ 0% RT (5/19)26% NRT (6/62)10% RT 39.7% NRT 10.6% NR




95 10 6 97 4 6 27 122 141 0 55

0 210 202 0 30 56 187 278 0 30 22

95 220 208 97 34 62 214 400 141 30 77

Krueger EA27





31 m

Cordeiro PG28





33 m

NR 17.7% (42) 20% 55.6% 37% (7/62) 11.3% 16% 17.75% NR 20% RT ¼ 51% NRT ¼ 14% RT (13/19) 68% NRT (19/62) 31% NR





21 m

17/28 ¼ 60%

Baschnagel AM17 Salgarello M18 Petersen A19 Drucker-Zertuche M20 Losken A21 Roostaeian J22 Radovanovic Z23 Delgado JF24 Cowen D25 Nava6 Tallet AV26

Goyal A29

NR ¼ not reported, w ¼ weeks, m ¼ months, y ¼ years, RT ¼ radiotherapy, NRT ¼ no radiotherapy, SRM ¼ skin reducing mastectomy, SSM ¼ skin sparing mastectomy, MRM ¼ modified radical mastectomy.

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Nava et al.1,6 reported final results ‘judged by plastic surgeons and patients as extremely satisfying, especially with regard to the optimal degree of ptosis and appropriate distribution of volume between the superior, inferior, medial and lateral aspects of the breast’ but, in their series there was no patient exposed to radiotherapy. The limitations of our study are lack of baseline scores, selection bias as patients who lost their implants could not be included and length of follow up, which is insufficient to comment on the long term incidence of capsular contracture. Although part of the data collection was retrospective, patients’ recruitment was in a prospective manner. We are planning to study the outcome of these two groups in long term follow up. Conclusions Skin reducing mastectomy is a very useful and simple technique to achieve better cosmetic outcomes in breast reconstruction. It is especially useful in large and ptotic breasts where additional skin can be used to provide vascularised coverage for the implant. Skin reducing mastectomy and immediate breast reconstruction with implant or implant expander is also a good option in patients unsuitable or unwilling for autologous breast reconstruction. There is no statistically significant increased rate of major complications like implant loss and capsular contracture when SRMIR is combined with radiotherapy. Patient reported outcome score in professional and social situations is lower in the radiotherapy group compared with women who did not receive radiotherapy. However, the overall patient satisfaction remains high even after radiotherapy. We advocate SRMIR with full discussion of all reconstructive options even in women who might need radiotherapy. This technique can also be used as immediate temporary option to preserve the skin envelope for a delayed autologous reconstruction in selected cases. Conflicts of interest None.

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Skin reducing mastectomy and immediate reconstruction: the effect of radiotherapy on complications and patient reported outcomes.

Skin reducing mastectomy, dermal sling and immediate implant reconstruction (SRMIR) is an emerging technique where, de-epithelialised inferior skin fl...
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