DOI: 10.1097/PRS.0b013e3181aa1003

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PMID: 19568045

Issn Print: 0032-1052

Publication Date: 2009/07/01


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Discussion

Joseph J. Disa

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Dr. Nahabedian describes the personal experience and philosophy of a single surgeon at a major, urban, academic medical center. Although his experience includes more than 1000 patients over 10 years, the details of this article are limited to the period from July of 2005 to July of 2007. During that period, he performed primary breast reconstruction in 236 women. Unilateral reconstruction was accomplished in 161 women and bilateral reconstruction in 75. Prosthetic devices were used in 26 percent and autologous tissue in 74 percent. Of the autologous tissue reconstructions, 93 percent were accomplished with a free flap [muscle-sparing free transverse rectus abdominis musculocutaneous (TRAM), deep inferior epigastric perforator (DIEP), and superior gluteal artery perforator flaps].
Dr. Nahabedian describes his consultation with the patients, emphasizing that his goal is not to raise expectations or “sell” a particular operation but rather to educate the patient in a realistic manner. This is accomplished through discussion, diagrams, and photographs. Procedural selection is geared toward patient desires, availability of donor sites, and expectations.
The topic of locally advanced breast cancer is addressed in this article. Currently there is a difference of opinion regarding the timing and type of breast reconstruction in the setting of locally advanced breast cancer. There are some who conclude that immediate reconstruction is safe and effective in this setting,1 while others believe that the negative effect the radiation imparts on the reconstruction warrants careful consideration for the use of immediate reconstruction.2 Dr. Nahabedian cites his own experience, noting a significantly higher rate of local recurrence when breast reconstruction precedes radiation in locally advanced breast cancer.3 Interestingly, in his series, the incidence of local recurrence was increased when autologous tissue reconstruction preceded radiation therapy, but the opposite was true with prosthetic reconstruction.
The variability in the detrimental effect of radiation therapy on breast reconstruction may be affected by regional differences in radiation therapy protocols. In our institution, there is no absolute as to the timing or type of reconstruction in patients with locally advanced breast cancer. Decisions are made in a multidisciplinary fashion taking into consideration patient preferences. Typically, if a patient desires autologous tissue reconstruction, the reconstruction is delayed until conclusion of the radiation and resolution of the acute postradiation skin changes. However, in patients who either are not candidates for autologous tissue or simply desire prosthetic reconstruction, it is my practice to proceed with immediate placement of a tissue expander after mastectomy whenever appropriate. Tissue expansion proceeds while the patient is receiving chemotherapy. Exchange of the tissue expander to a permanent implant occurs 3 to 4 weeks after the chemotherapy concludes and 2 to 4 weeks before the onset of adjuvant radiation therapy.4 This approach has the advantage of reducing the profile of the reconstructed breast that needs to be irradiated, thus limiting the damage to local uninvolved tissues. Recently, the use of delayed-immediate reconstruction has been popularized by Kronowitz.5 In this technique, the expander is either completely or nearly completely deflated before radiation therapy but left intact. It is then rapidly reexpanded after radiation therapy, followed by conversion to a permanent implant or autologous tissue.
Dr. Nahabedian correctly points out that both autologous tissue and prosthetic devices are useful for a variety of breast sizes and shapes. Clearly there are some patients in whom one technique is superior to another; however, many patients are excellent candidates for either method of reconstruction. In these situations, it is imperative that the physician present the various options in an unbiased manner to truly achieve informed consent.
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