Part of the multidisciplinary approach to cancer care involves surgical intervention. This is harmoniously interwoven through the efforts of the surgical oncologist and the reconstructive surgeon. As elegantly pointed out by Drs. Hasen, Few, and Fine, the reconstructive surgeon’s role in the management of malignancy is critical, involving the restoration of form and function. Sometimes, as in breast reconstruction, quality of life is improved by the restoration of form; other times, as in head and neck reconstruction, it is improved by the restoration of form and function. In fact, due to the significant morbidity associated with major ablation of head and neck cancer, such radical surgery would not be feasible without concomitant reconstruction.
The use of both immediate and delayed reconstruction following mastectomy is increasing. Without question, quality-of-life measurements demonstrate the positive aspects of immediate breast reconstruction. As described in this article, several different types of breast reconstruction are available, and each has its own inherent advantages and disadvantages. Adding to the complexity of breast reconstruction is the increasing role of radiation therapy in patients with positive surgical margins, tumors > 5 cm in size, and four or more positive lymph nodes.
Adjuvant radiation therapy to the chest wall has a significant effect on breast reconstruction, regardless of type. Thus, there is growing concern about the role of immediate reconstruction in patients who are going to receive adjuvant radiation therapy. Unfortunately, the reconstructive surgeon is generally not aware of this detail, which only becomes evident after the final pathology is reviewed.
Irradiation produces a higher incidence of complications including partial flap loss and fat necrosis in patients undergoing autologous breast reconstruction (ie, a transverse rectus abdominis myocutaneous [TRAM] flap procedure) and a higher incidence of capsular contracture, infection, and implant loss in those who have prosthetic breast reconstruction.[1,2] Despite these findings, patient satisfaction remains high in the majority.
The long-term effects of radiation therapy and breast reconstruction are unknown. It is clear, however, that physicians need to discuss the increased risk of complications with patients who will require irradiation. The table included in the article by Drs. Hasen, Few, and Fine is an excellent example of how this is accomplished. Patients who have just been informed that they will require a mastectomy are often at a psychological disadvantage when meeting with their plastic surgeon to discuss reconstruction. In this setting, providing patients with printed information to review after the consultation is helpful.
One other topic regarding breast reconstruction merits mention, and that is the use of the perforator flap. With this technique, the surgeon takes skin and subcutaneous fat from either the abdominal or gluteal region, but the muscle is preserved. Proponents of this technique report a reduced donor site morbidity and shorter recovery. Opponents note an increased operative time, a higher incidence of complications, and perhaps a reduced flap survival rate. Microsurgical expertise is mandatory with this technique, which is still evolving. Its ultimate role in breast reconstruction remains to be defined.[4,5]