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Table 2: Comparisons of clinical characteristics of latissimus dorsi flap or other autologous tissue flap.
patients who received neoadjuvant chemotherapy Immediate reconstruction with an autologous tissue flap
with or without SSM (n = 243) was affected by the availability of the breast skin envelope
Characteristics Non-SSM SSM P as seen in the significantly increased utilization of flaps in
(n = 74) (n = 169) non‑SSM as opposed to SSM patients. Preservation of the
Age breast skin envelope thus appeared most beneficial for
Mean 46.8 45.8 0.4 immediate reconstruction with a tissue expander followed
Median (range) 47 (29-69) 47 (25-75) by an implant.
Race Although the use of NAC was not associated with an
White 53 (29.0) 130 (71.0) 0.4 increase in the use of SSM and IBR (71.4% in all patients,
Other 21 (35.0) 39 (65.0) vs. 69.5% in NAC patients, P = 0.3), it was associated
Clinical TNM stage with the choice of reconstruction (P < 0.0001). NAC
Stage II 46 (24.5) 142 (75.5) < 0.0001 had a moderate effect on the proportion of patients
Stage III 28 (50.9) 27 (49.1)
Tumor size (cm) who underwent implant‑based or autologous tissue flap
Mean 4.6 3.5 0.025* reconstruction, and a larger proportional difference in
Median (range) 4 (0.8-20) 3 (0.5-14) patients who underwent reconstruction with a latissimus
Year of surgery dorsi flap plus breast implant. The authors suspect that
2007 15 (36.6) 26 (63.4) 0.3 less breast skin was sacrificed during mastectomies in
2008 23 (34.3) 44 (65.6) the NAC cohort, resulting in this difference. However,
2009 36 (26.7) 99 (73.3) while fewer SSM patients who had NAC had a latissimus
Reconstruction type dorsi flap plus breast implant than those who did not
Tissue expander 20 (27.0) 92 (54.4) < 0.0001 have NAC (5.9% vs. 7.2%), this finding was not statistically
followed by implant significant (P = 0.765, Chi‑square).
Autologous 34 (46.0) 67 (39.6)
Latissimus dorsi flap 20 (27.0) 10 (5.9) While one purpose of NAC is to facilitate the conversion
of mastectomy to BCS, the authors hypothesized that in
Data are shown as n (%). *Rank sum test. SSM: Skin‑sparing mastectomy, patients with locally‑advanced breast cancer (i.e. stage II
TNM: Tumor node metastasis
and III) it can also reduce the morbidity of mastectomy
by converting patients who would otherwise receive
with immediate reconstruction (P < 0.0001). Among the non‑SSM to SSM. There was a significantly higher
patients who received NAC, the mean clinical tumor size percentage of Stage III breast cancer patients in the
for the patients who underwent SSM was 3.5 cm (range, NAC cohort (22.6% vs. 14.7%, P < 0.05). NAC patients
0.5‑14 cm) compared with 4.6 cm (range, 0.8‑20 cm) furthermore had larger tumors on average (3.5 cm, vs.
for those who underwent non‑SSM (P = 0.025). Of the 3.1 cm for non‑neoadjuvant patients), potentially allowing
patients who received NAC followed by SSM, 54.4% had the use of SSM in more patients who would otherwise
implant‑based reconstruction, 39.6% had autologous not be candidates. Additionally, a greater percentage
tissue flap reconstruction only, and 5.9% had a latissimus of SSM patients who had NAC had implant‑based breast
dorsi myocutaneous flap plus a breast implant, vs. 27%, reconstruction than those who did not have NAC, which
46%, and 27% for non‑SSM patients, respectively. may indicate that more mastectomy skin was preserved at
Figure 1 displays by year the percentages of patients the time of SSM. Indeed, the authors found a significant
with stage II and III disease who underwent SSM, with or difference in the size of excised skin in non‑SSM vs. SSM
2
2
without NAC. In the latter years of this study, a statistically patients (56.2 cm vs. 22.3 cm , P < 0.01). It is our current
significant increase occurred in the percentage of patients practice to reconstruct non‑SSM patients with either a
with both stage II and III disease who underwent SSM latissimus dorsi flap + implant or autologous tissue, thus
with immediate reconstruction. This increase in SSM with highlighting the role of mastectomy skin preservation in
immediate reconstruction was most notable in patients shaping reconstructive choices.
with stage III disease, especially between the time periods Breast conservation surgery has become an integral
2007 and 2009. part of the management of breast cancer patients.
It provides effective locoregional management and
DISCUSSION reduces the negative psychosocial impact related to
mastectomy. [16,17] Its oncologic safety is now documented;
In this report, we present our experience with patients it does not increase local or distant recurrence, nor
with clinical or pathological Stage II and III breast cancer does it adversely affect disease‑free or overall survival.
who underwent IBR. We found that approximately 75% of Furthermore, there is no significant delay in detection
patients with stage II disease and about half of patients of cancer recurrence. [18‑21] However, many patients still
with stage III disease underwent SSM. Patients who require mastectomies as standard treatment for breast
received NAC followed by SSM with IBR had larger clinical cancer. [8,22,23] Many institutions have adopted the use
tumors than those who did not. More than half of these of NAC to facilitate the conversion of mastectomy to
patients ultimately had implant‑based reconstruction, breast‑conserving surgery or inoperable tumors to
without the need for additional skin from either a operable tumors in women with locally advanced breast

Plast Aesthet Res || Vol 2 || Issue 1 || Jan 15, 2015 19