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]
1. Proulx GM, Loree T, Edge S, et al: Outcome with postmastectomy radiation
with transverse rectus abdominis musculocutaneous flap breast reconstruction. Am
Surg 68:410-413, 2002.
2. Tran NV, Chang DW, Gupta A, et al: Comparison of immediate and delayed
free TRAM flap breast reconstruction in patients receiving postmastectomy
radiation therapy. Plast Reconstr Surg 108:78-82, 2001.
3. Krueger EA, Wilkins EG, Strawderman M, et al: Complications and patient
satisfaction following expander/implant breast reconstruction with and without
radiotherapy. Int J Radiat Oncol Biol Phys 49:713-721, 2001.
4. Nahabedian MY, Momen B, Galdino G, et al: Breast reconstruction with the
free TRAM or DIEP flap: Patient selection, choice of flap, and outcome. Plast
Reconstr Surg 110:466-477, 2002.
5. Blondeel PN: The sensate free superior gluteal artery perforator (S-GAP)
flap: A valuable alternative in autologous breast reconstruction. Br J Plast
Surg 52:185-193, 1999.
6. Disa JJ, Pusic AL, Hidalgo DH, et al: Simplifying microvascular head and
neck reconstruction: A rational approach to donor site selection. Ann Plast Surg
7. Hidalgo DA, Disa JJ, Cordeiro PG, et al: A review of 716 consecutive free
flaps for oncologic surgical defects: Refinement in donor-site selection and
technique. Plast Reconstr Surg 102:722-734, 1998.
8. Cordeiro PG, Disa JJ, Hidalgo DA, et al: Reconstruction of the mandible
with osseous free flaps: A 10-year experience with 150 consecutive patients.
Plast Reconstr Surg 104:1314-1320, 1999.
9. Disa JJ, Cordeiro PG: Mandible reconstruction with microvascular surgery.
Semin Surg Oncol 19:226-234, 2000.
10. Disa JJ, Cordeiro PG: Reconstruction of the hypopharynx and cervical
esophagus. Clin Plast Surg 28:349-360, 2001.