To the Editor: Cordeiro (Oct. 9 issue)1 describes a patientwho may undergo postoperative radiation therapy after mastectomy.He states that the best therapeutic option would be prosthesis-basedbreast reconstruction. Because of the patient's limited abdominaltissue, the possible use of the superior gluteal artery perforator(SGAP) flap is mentioned but rejected in favor of an expander–implantapproach. However, this operative approach is at odds with theresults of several studies confirming the significantly increasedrisk of capsular contracture and other secondary complicationsin patients who received radiation as compared with patientswith implants who did not receive radiation2,3 and as comparedwith patients undergoing autogenous breast reconstruction whoreceived radiation.4 Hence, we would strongly recommend autogenous-tissuetransfer in this patient, so as to avoid the radiotherapy-relatedrisk of formation of a capsular contracture. Free microvasculartransplantation of the SGAP flap would provide an excellentlong-lasting cosmetic result in this patient. This proceduremay be performed with insufficient abdominal tissue, as in thepatient described by Cordeiro, or even after previous transferof a deep inferior epigastric perforator flap for autogenousreconstruction of the contralateral breast (Figure 1).
Figure 1. A 57-Year-Old Patient after Reconstruction of Her Breasts.
The patient underwent delayed autogenous reconstruction of her right breast after radiotherapy and the formation of a capsular contracture. Six months later, delayed reconstruction of the right breast was performed with the transfer of a free microvascular deep inferior epigastric perforator flap. Her left breast was reconstructed with the transfer of a free microvascular superior gluteal artery perforator flap after complete mastectomy and radiotherapy. Nipple–areola complexes were reconstructed with skin grafts obtained from the groin (for the areolae) and local skin flaps (for the nipples). Good symmetry and a satisfactory and long-lasting cosmetic result 1 year after the second reconstruction are shown.
Justus P. Beier, M.D. Raymund E. Horch, M.D. Alexander D. Bach, M.D. University Hospital of Erlangen 91054 Erlangen, Germany justus.beier{at}uk-erlangen.de
References
Cordeiro PG. Breast reconstruction after surgery for breast cancer. N Engl J Med 2008;359:1590-1601. [Free Full Text]
Cordeiro PG, McCarthy CM. A single surgeon's 12-year experience with tissue expander/implant breast reconstruction. II. An analysis of long-term complications, aesthetic outcomes, and patient satisfaction. Plast Reconstr Surg 2006;118:832-839. [CrossRef][Web of Science][Medline]
Behranwala KA, Dua RS, Ross GM, Ward A, A'Hern R, Gui GP. The influence of radiotherapy on capsule formation and aesthetic outcome after immediate breast reconstruction using biodimensional anatomical expander implants. J Plast Reconstr Aesthet Surg 2006;59:1043-1051. [CrossRef][Web of Science][Medline]
Pomahac B, Recht A, May JW, Hergrueter CA, Slavin SA. New trends in breast cancer management: is the era of immediate breast reconstruction changing? Ann Surg 2006;244:282-288. [Erratum, Ann Surg 2007;245(3):table of contents.] [CrossRef][Web of Science][Medline]
To the Editor: In his review of reconstruction after surgeryfor breast cancer, Cordeiro draws attention to the lack of guidelineson breast reconstruction. The Association of Breast Surgeryat BASO (the British Association of Surgical Oncology), theBritish Association of Plastic, Reconstructive and AestheticSurgeons, and the Training Interface Group in Breast Surgeryrecently have produced a guide to good practice1 in which wehave defined the processes and standards for surgical teamsto ensure that the appropriate equipment, facilities, training,and time are available for the safe performance of oncologicreconstructive breast surgery.
Although we agree that controlled trials are difficult to conductin this group of women, the proposed multicenter, randomizedQuality of Life after Mastectomy and Breast Reconstruction trial2in the United Kingdom will assess the impact of the type andtiming of breast reconstruction on quality of life after mastectomy.
We hope our guidance will help patients, providers, and payersto understand that there are standards for the safest possibleperformance of breast reconstruction after breast cancer.
Martin J.R. Lee, M.Sc., F.R.C.S. Hugh M. Bishop, D.M., F.R.C.S. Association of Breast Surgery London WC2A 3PE, United Kingdom martin.lee{at}uhcw.nhs.uk
Fazel T. Fatah, F.R.C.S. British Association of Plastic Reconstructive and Aesthetic Surgeons London WC2A 3PE, United Kingdom
Potter S, Winters ZE. The QUEST study: a multicentre randomised trial to assess the impact of the type and timing of breast reconstruction on quality of life following mastectomy. Breast Cancer Res 2008;10:Suppl 2:P87. abstract. (Also available at http://breast-cancer-research.com/content/10/S2/P87.)
To the Editor: In his review of breast reconstruction with siliconeimplants, Cordeiro states "it is now clear that silicone andbreast implants are not linked to cancer, immunologic or neurologicdisorders, or any other systemic disease." However, four referencescited by the author as showing silicone was safe all showedthat silicone was not entirely safe.
Sanchez-Guerrero et al.1 found significant morning stiffnessas a sign of immune activation, Karlson et al.2 described significantantibodies to single-stranded DNA, and Gaubitz et al.3 foundsignificant antinuclear-antibody positivity and neuropathy.Arthralgias, tingling, myalgias, and fatigue occurred in 50to 75% of these patients. The magnetic resonance imaging studyreported on by Brown et al.4 showed fibromyalgia in 25% of patientswith extracapsular rupture and in 13% of the other patients(expected rate, 3%). These findings point to a new undefinedsyndrome.
Our experience confirms the findings of Rohrich et al.5 thatimplant removal stabilizes and ultimately improves these symptoms.Plastic surgeons and rheumatologists need to get together todefine the syndrome, study the influence of implant removal,and establish a health assessment-like questionnaire that plasticsurgeons could use to counsel patients.
Frank B. Vasey, M.D. Louis Ricca, M.D. University of South Florida College of Medicine Tampa, FL 33612 fvasey{at}health.usf.edu
References
Sanchez-Guerrero J, Colditz GA, Karlson EW, Hunter DJ, Speizer FE, Liang MH. Silicone breast implants and the risk of connective-tissue diseases and symptoms. N Engl J Med 1995;332:1666-1670. [Free Full Text]
Karlson EW, Hankinson SE, Liang MH, et al. Association of silicone breast implants with immunologic abnormalities: a prospective study. Am J Med 1999;106:11-19. [Web of Science][Medline]
Gaubitz M, Jackisch C, Domschke W, Heindel W, Pfleiderer B. Silicone breast implants: correlation between implant ruptures, magnetic resonance spectroscopically estimated silicone presence in the liver, antibody status and clinical symptoms. Rheumatology (Oxford) 2002;41:129-135. [CrossRef][Medline]
Brown SL, Pennello G, Berg WA, Soo MS, Middleton MS. Silicone gel breast implant rupture, extracapsular silicone, and health status in a population of women. J Rheumatol 2001;28:996-1003. [Free Full Text]
Rohrich RJ, Kenkel JM, Adams WP, Beran S, Conner WC. A prospective analysis of patients undergoing silicone breast implant explantation. Plast Reconstr Surg 2000;105:2529-2537. [CrossRef][Web of Science][Medline]
To the Editor: Cordeiro judiciously addresses the issue of reconstructivebreast surgery in patients undergoing mastectomy, with a specialfocus on the aesthetic outcome. As radiation oncologists, weagree that breast reconstruction is problematic in previouslyirradiated tissues, significantly increasing the risk of subsequentcomplications. Immediate reconstructive surgery also interactsunfavorably with postmastectomy radiation therapy. The initiationof radiotherapy is delayed, and anatomical changes induced byimplant-based procedures create technical difficulties.1 Radiationtreatment planning is technically altered, with major compromisesin terms of optimal chest-wall coverage, avoidance of the heart,minimization of the radiation dose to the lung, and treatmentof the ipsilateral internal mammary lymph nodes, leading topotential uncertainties in the efficacy of postmastectomy radiationtherapy.2 The recent availability of intensity-modulated radiationtreatment techniques may improve the quality of dose distributionafter reconstructive surgery.3 Multidisciplinary preoperativediscussion remains necessary in order to optimize the timingof breast reconstruction in patients with high-risk breast cancer.
Cyrus Chargari, M.D. Youlia M. Kirova, M.D. Alain Fourquet,M.D. Institut Curie 75005 Paris, France chargari-vdg{at}hotmail.fr
References
Chawla AK, Kachnic LA, Taghian AG, Niemierko A, Zapton DT, Powell SN. Radiotherapy and breast reconstruction: complications and cosmesis with TRAM versus tissue expander/implant. Int J Radiat Oncol Biol Phys 2002;54:520-526. [CrossRef][Web of Science][Medline]
Motwani SB, Strom EA, Schechter NR, et al. The impact of immediate breast reconstruction on the technical delivery of postmastectomy radiotherapy. Int J Radiat Oncol Biol Phys 2006;66:76-82. [Web of Science][Medline]
Koutcher L, Ballangrud A, Cordeiro P, McCormick B, Hunt M, Beal K. Postmastectomy intensity modulated radiation therapy (IMRT) in women who undergo immediate breast reconstruction. Int J Radiat Oncol Biol Phys 2007;69:Suppl:S222-S222.
The author replies: Patients with stage III breast cancer whoundergo postmastectomy radiation therapy often have limitedoptions for reconstruction. Radiation therapy to the chest wallcan injure normal tissues and adversely affect the aestheticoutcomes in both implant-based and autologous tissue–basedreconstruction. However, a significant percentage of patientswith immediate implant reconstructions can attain acceptableresults despite postoperative radiation therapy and —most importantly — patient satisfaction remains high.1Patients who are not satisfied can undergo implant removal andsubsequent reconstruction with autologous tissue such as a gluteusflap, as described by Beier et al. Irradiated flaps have beenshown to have a greater than 85% rate of late complicationsand require a high rate (28%) of secondary flaps for salvage.2If the patient were to proceed with an immediate gluteus reconstruction,the postoperative radiation would potentially ruin the result;therefore, the recommendation for immediate implant reconstructionmakes sense.
The silicone controversy has largely been resolved, since mostlarge studies provide support for the concept that the use ofsilicone is safe. A court-appointed National Science Panel performeda systematic review of all studies providing scientific evidenceof any association between silicone breast implants and alltypes of systemic and connective diseases and concluded thatthere was no association.3 The current position of the Foodand Drug Administration (FDA) is that "in the past decade, anumber of independent studies have examined whether siliconegel–filled breast implants are associated with connectivetissue disease or cancer. The studies, including a report bythe Institute of Medicine, have concluded there is no convincingevidence that breast implants are associated with either ofthese diseases."4 The FDA approved the use of silicone implants"based on a thorough review of each company's clinical (core)and preclinical studies, a review of studies by independentscientific bodies and deliberations of advisory panels of outsideexperts that heard public comment from hundreds of stakeholders."4
Finally, Chargari et al. summarize some of the problems associatedwith reconstruction in patients who have undergone or potentiallywill undergo radiation therapy. However, it is possible to deliveradequate postoperative radiation with reconstruction when thepatient is cared for by a multidisciplinary team that addressesall the different issues surrounding both oncologic treatmentand reconstructive options.1,5
Peter G. Cordeiro, M.D. Memorial Sloan-Kettering Cancer Center New York, NY 10065
References
Cordeiro PG, Pusic AL, Disa JJ, McCormick B, VanZee K. Irradiation after immediate tissue expander/implant breast reconstruction: outcomes, complications, aesthetic results, and satisfaction among 156 patients. Plast Reconstr Surg 2004;113:877-881. [CrossRef][Web of Science][Medline]
Tran NV, Chang DW, Gupta A, Kroll SS, Robb GL. Comparison of immediate and delayed free TRAM flap breast reconstruction in patients receiving postmastectomy radiation therapy. Plast Reconstr Surg 2001;108:78-82. [CrossRef][Web of Science][Medline]
Tugwell P, Wells G, Peterson J, et al. Do silicone breast implants cause rheumatologic disorders? A systematic review for a court-appointed National Science Panel. Arthritis Rheum 2001;44:2477-2484. [CrossRef][Web of Science][Medline]
FDA approves silicone gel-filled breast implants after in-depth evaluation. Rockville, MD: Food and Drug Administration, 2006. (Accessed January 5, 2009, at http://www.fda.gov/bbs/topics/NEWS/2006/NEW01512.html.)
McCormick B, Wright J, Cordeiro PG. Breast reconstruction combined with radiation therapy: long-term risks and factors related to decision making. Cancer J 2008;14:264-268. [Web of Science][Medline]
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