Right or Wrong, Implants for Breast Reconstruction Are on the Rise
2
Right or Wrong, Implants for Breast Reconstruction Are on the Rise Patrick B. Garvey, MD The article, “A paradigm shift in U.S. breast reconstruction: increasing implant rates,” 1 provides valuable data to verify several trends that many breast surgeons and plastic surgeons have suspected for years. Using the Nationwide Inpatient Sample database, Albornoz and colleagues demonstrated that over the past 10 years women have increasingly under- gone immediate rather than delayed breast reconstruction and implant rather than autologous breast reconstruction. Furthermore, bilateral mastectomies are on the rise while unilateral mastectomies are decreasing, and women who choose bilateral mastectomies are more likely to pursue reconstruction than women who choose unilateral mastecto- mies. For those women who choose reconstruction after bilat- eral mastectomy, implant rather than autologous flap reconstructions are overwhelmingly performed. A number of points deserve mention. Partial mastectomies were excluded from the analysis. It would have been inter- esting to understand how the increase in the use of oncoplastic techniques following segmental mastectomy affected the observed trends in mastectomy reconstruction. At my institu- tion, The University of Texas MD Anderson Cancer Center, plastic surgeons now routinely perform breast reconstruction following lumpectomy, using reduction mammoplasty or mas- topexy oncoplastic techniques to minimize the potential for contour deformity following radiation therapy. Our success with this program has resulted in our breast surgeons feeling comfortable about expanding the indications for breast conser- vation surgery and has, thus, decreased the need for mastecto- mies. Using oncoplastic techniques, we can now achieve satisfactory aesthetic outcomes for lumpectomies that would have previously disfigured a woman’s breast; we can thus enable women to avoid the potentially more onerous process of breast reconstruction following mastectomy. Another trend during this 10-year period that bears discussion was the more liberal use of, and increasing indi- cations for, postmastectomy radiation therapy (PMRT), not only to prevent local recurrence of breast cancer but also for the survival advantage it has been shown to provide. Whereas 10 years ago immediate reconstructions were commonplace and radiation treatment that included the reconstruction site an uncommon phenomenon, now recon- structive surgeons increasingly must either take measures to avoid direct radiation therapy injury to the reconstruction or simply choose to allow the reconstruction to be irradi- ated. 2 Many surgeons still choose to avoid the potentially deleterious effects of PMRT to the reconstruction; thus, increasing PMRT rates are likely affecting the types and rates of immediate breast reconstructions. Many centers now favor a “staged” or “delayed-immediate” approach to breast reconstruction, whereby a tissue expander is placed at the time of skin-sparing mastectomy and the definitive implant or autologous reconstruction is delayed until the final pathologic report from the mastectomy is available and a final decision regarding the need for PMRT has been rendered. 3-5 Albornoz and colleagues’ analysis excluded delayed reconstructions, and thus, autologous reconstructions fol- lowing standard mastectomy or initial tissue expander place- ment may have been missed using their methodology. It has been my experience that more autologous reconstructions now follow initial tissue expander reconstruction, as mastec- tomy patients, by definition, typically present with more- advanced-stage breast cancers that will potentially require PMRT, the less-advanced-stage breast cancers having been selected out by the surgical oncologists for breast conservation therapy. The rise of staged reconstructions may have contrib- uted to the higher implant versus autologous flap reconstruction rates observed in this study. It also may have contributed to the rise in immediate reconstructions observed, as patients who previously were known to require PMRTwere typically offered delayed reconstruction after completion of their PMRT, whereas more of those patients now undergo tissue expander placement in anticipation of definitive reconstruction. The rise in bilateral mastectomy and reconstruction is a possible cause for concern. More women are choosing to undergo contralateral prophylactic mastectomy (CPM), whether oncologically justified or not, and when they do, they are more often choosing implant-based reconstructions. Improved techniques and materials for implant-based recon- structions, such as nipple-sparing mastectomy, cohesive sili- cone implants, acellular dermal matrix, and fat grafting, are enabling plastic surgeons to deliver superior aesthetic results with implants compared to what was previously possible. This may be contributing to the increase in bilateral mastec- tomies, as supported by the authors’ observation that women who chose bilateral mastectomies were more likely to also pursue breast reconstruction. The rise in bilateral reconstruc- tions also begs the question: Are reconstructive surgeons performing more implant-based reconstructions to avoid the difficulties of either autologous reconstruction or obtain- ing a symmetrical outcome with unilateral implant-based reconstruction? Breast Diseases: A Year Book Ò Quarterly 129 Vol 24 No 2 2013
Transcript of Right or Wrong, Implants for Breast Reconstruction Are on the Rise
Right or Wrong, Implants for BreastReconstruction Are on the Rise
Patrick B. Garvey, MD
The article, “A paradigm shift in U.S. breast reconstruction:increasing implant rates,”1 provides valuable data to verifyseveral trends that many breast surgeons and plastic surgeonshave suspected for years. Using the Nationwide InpatientSample database, Albornoz and colleagues demonstratedthat over the past 10 years women have increasingly under-gone immediate rather than delayed breast reconstructionand implant rather than autologous breast reconstruction.Furthermore, bilateral mastectomies are on the rise whileunilateral mastectomies are decreasing, and women whochoose bilateral mastectomies are more likely to pursuereconstruction than women who choose unilateral mastecto-mies. For those women who choose reconstruction after bilat-eral mastectomy, implant rather than autologous flapreconstructions are overwhelmingly performed.
A number of points deservemention. Partial mastectomieswere excluded from the analysis. It would have been inter-esting to understand how the increase in the use of oncoplastictechniques following segmental mastectomy affected theobserved trends in mastectomy reconstruction. At my institu-tion, The University of Texas MD Anderson Cancer Center,plastic surgeons now routinely perform breast reconstructionfollowing lumpectomy, using reduction mammoplasty or mas-topexy oncoplastic techniques to minimize the potential forcontour deformity following radiation therapy. Our successwith this program has resulted in our breast surgeons feelingcomfortable about expanding the indications for breast conser-vation surgery and has, thus, decreased the need for mastecto-mies. Using oncoplastic techniques, we can now achievesatisfactory aesthetic outcomes for lumpectomies that wouldhave previously disfigured a woman’s breast; we can thusenable women to avoid the potentially more onerous processof breast reconstruction following mastectomy.
Another trend during this 10-year period that bearsdiscussion was the more liberal use of, and increasing indi-cations for, postmastectomy radiation therapy (PMRT), notonly to prevent local recurrence of breast cancer but alsofor the survival advantage it has been shown to provide.Whereas 10 years ago immediate reconstructions werecommonplace and radiation treatment that included thereconstruction site an uncommon phenomenon, now recon-structive surgeons increasingly must either take measuresto avoid direct radiation therapy injury to the reconstruction
or simply choose to allow the reconstruction to be irradi-ated.2 Many surgeons still choose to avoid the potentiallydeleterious effects of PMRT to the reconstruction; thus,increasing PMRT rates are likely affecting the types andrates of immediate breast reconstructions. Many centersnow favor a “staged” or “delayed-immediate” approach tobreast reconstruction, whereby a tissue expander is placedat the time of skin-sparing mastectomy and the definitiveimplant or autologous reconstruction is delayed until thefinal pathologic report from the mastectomy is availableand a final decision regarding the need for PMRT has beenrendered.3-5
Albornoz and colleagues’ analysis excluded delayedreconstructions, and thus, autologous reconstructions fol-lowing standard mastectomy or initial tissue expander place-ment may have been missed using their methodology. It hasbeen my experience that more autologous reconstructionsnow follow initial tissue expander reconstruction, as mastec-tomy patients, by definition, typically present with more-advanced-stage breast cancers that will potentially requirePMRT, the less-advanced-stage breast cancers having beenselected out by the surgical oncologists for breast conservationtherapy. The rise of staged reconstructions may have contrib-uted to the higher implant versus autologous flap reconstructionrates observed in this study. It also may have contributed to therise in immediate reconstructions observed, as patients whopreviouslywere known to require PMRTwere typically offereddelayed reconstruction after completion of their PMRT,whereas more of those patients now undergo tissue expanderplacement in anticipation of definitive reconstruction.
The rise in bilateral mastectomy and reconstruction isa possible cause for concern. More women are choosingto undergo contralateral prophylactic mastectomy (CPM),whether oncologically justified or not, and when they do,they are more often choosing implant-based reconstructions.Improved techniques and materials for implant-based recon-structions, such as nipple-sparing mastectomy, cohesive sili-cone implants, acellular dermal matrix, and fat grafting, areenabling plastic surgeons to deliver superior aesthetic resultswith implants compared to what was previously possible.This may be contributing to the increase in bilateral mastec-tomies, as supported by the authors’ observation that womenwho chose bilateral mastectomies were more likely to alsopursue breast reconstruction. The rise in bilateral reconstruc-tions also begs the question: Are reconstructive surgeonsperforming more implant-based reconstructions to avoidthe difficulties of either autologous reconstruction or obtain-ing a symmetrical outcome with unilateral implant-basedreconstruction?
Breast Diseases: A Year Book� Quarterly 129Vol 24 No 2 2013
It is important that plastic surgeons thoughtfully counseltheir patients about the increased risks associated with CPMand reconstruction, particularly in those patients for whomthere would be minimal potential oncologic benefit toCPM, as complication rates are significantly higher for bilat-eral versus unilateral breast reconstruction, irrespective ofwhether the reconstruction is performed with implants orautologous flaps.6 The decision to remove a normal breastshould never be based on reconstructive issues and shouldbe reserved for either patients who will receive an oncologicbenefit or patients who, after appropriate counseling, havea strong psychological need to have the normal breastremoved. As reconstructive breast surgeons, we need toensure that we do not allow this growth of bilateral mastec-tomy to reach epidemic proportions.
Albornoz and colleagues deserve praise for their study.Even without allowing for the effects of PMRT and breastconservation therapy, the observed trends in this studyare enormously valid. Perhaps the most important factoraffecting the rates of implant versus autologous reconstruc-tion is compensation. The authors’ multivariate regressionanalysis of predictive factors for implant reconstructionclearly demonstrated that Medicare recipients more oftenreceived implants than privately insured patients. Withoutjust compensation for the greatly increased effort and timerequired for autologous breast reconstruction, women willfind it increasingly challenging to secure access to autologousbreast reconstruction. More studies that precisely define theconsequences and long-term costs of complications relatedto inappropriate use of implants rather than autologousflaps in selected patient populations such as the obese7 orpatients requiring radiation therapy are critical to prevent
130 Breast Diseases: A Year Book� Quarterly
Vol 24 No 2 2013
short-term financial pressures from compromising the qualityof reconstructive surgery provided by plastic surgeons towomen fighting breast cancer.
References1. Albornoz CR, Bach PB, Mehrara BJ, et al. A paradigm shift in
U.S. breast reconstruction: increasing implant rates. PlastReconstr Surg. 2013;131:15-23.
2. Ho A, Cordeiro P, Disa J, et al. Long-term outcomes in breastcancer patients undergoing immediate 2-stageexpander/implant reconstruction and postmastectomyradiation. Cancer. 2012;118:2552-2559.
3. Kronowitz SJ, Hunt KK, Kuerer HM, et al. Delayed-immediate breast reconstruction. Plast Reconstr Surg. 2004;113:1617-1628.
4. Kronowitz SJ, Kuerer HM. Advances and surgical decision-making for breast reconstruction. Cancer. 2006;107:893-907.
5. Kronowitz SJ, Lam C, Terefe W, et al. A multidisciplinaryprotocol for planned skin-preserving delayed breastreconstruction for patients with locally advanced breast cancerrequiring postmastectomy radiation therapy: 3-year follow-up.Plast Reconstr Surg. 2011;127:2154-2166.
6. Crosby MA, Garvey PB, Selber JC, et al. Reconstructiveoutcomes in patients undergoing contralateral prophylacticmastectomy. Plast Reconstr Surg. 2011;128:1025-1033.
7. Garvey PB, Villa MT, Rozanski AT, Liu J, Robb GL,Beahm EK. The advantages of free abdominal-based flapsover implants for breast reconstruction in obese patients. PlastReconstr Surg. 2012;130:991-1000.
Adherence to Hormonal Therapy in BreastCancer: An Advocate’s Perspective
Mary T. Aalto, BA
It is one of the most enduring successes in oncology: adju-vant hormonal therapy has consistently reduced recurrenceand mortality rates in hormone-sensitive breast cancer forover 3 decades.1 Widely available as tamoxifen and aroma-tase inhibitors, hormonal agents are well studied, easy touse, and have saved many thousands of lives. Yet, defyinglogic, nearly 1 in 4 breast cancer patients discontinue their
hormonal medications within the first year of treatment,with 50% of patients becoming nonadherent by year 4 andthereby failing to complete the recommended 5 years oftreatment that has been shown to prolong survival.2 Notably,25% of those who discontinue their medicine entirely do notinform their doctors of this decision.3 As a cancer survivorand patient advocate, I have to wonder: how is it that patientsfaced with life-threatening diagnoses turn away from treat-ment proven to save lives, and what can be done about it?
This counterintuitive behavior, well documented in themedical literature across various diseases and medications,is drawing increased attention as new quality care measuresare evaluated throughout the healthcare system. An estimated
![Biodegradable implants for orbital wall fracture reconstruction · [1]. Generally, alloplastic orbital implants are classified as bio-degradable and non-biodegradable materials. Non-resorbable](https://static.fdocuments.in/doc/165x107/6016c178b30cc600012ae1c8/biodegradable-implants-for-orbital-wall-fracture-1-generally-alloplastic-orbital.jpg)
