Incidence and Outcomes of Completion Mastectomy following Oncoplastic Reduction

A Case Series

Nusaiba F. Baker, PhD; Ciara A. Brown, MD; Toncred M. Styblo, MD; Grant W. Carlson, MD; Albert Losken, MD

Disclosures

Plast Reconstr Surg Glob Open. 2022;10(3):e4151 

In This Article

Abstract and Introduction

Abstract

Background: Patients occasionally need completion mastectomy (CM) following oncoplastic reduction for various reasons necessitating definitive reconstructive techniques. The purpose of this study was to evaluate those patients who required CM following oncoplastic reduction and evaluate indications, technique, and outcomes.

Methods: Patients who underwent a completion mastectomy at some time point following the oncoplastic reduction were identified. Factors that influenced CM and additional reconstruction were analyzed. All statistical analysis was conducted using the IBM SPSS Statistics 27.0 (IBM Corp.).

Results: A total of 29 patients (5.3%) underwent CM during the study period with an average follow-up of 3 years since the original procedure. The most common reasons were positive margins (20/29, 69.0%) and recurrence (8/29, 27.6%). Twenty-two had reconstructive procedures (75.9%) and seven did not (24.1%). The patients who underwent CM and reconstruction were significantly younger (49.2 years) than those who had no reconstruction (64.3 years, P = 0.004). The most common type of reconstruction was transverse rectus abdominis myocutaneous (TRAM)/deep inferior epigastric perforator (DIEP) flap (12/22, 54.5%), followed by latissimus (6/22, 27.3%) and tissue expander (3/22, 13.6%). The complication rate in the CM group was 24% (N = 7/29), which included two seromas (6.9%), followed by infection, fat necrosis, mastectomy skin necrosis, and donor site necrosis (3.4% each).

Conclusions: Completion mastectomy is indicated typically for positive margins or recurrence. Reconstruction is performed more frequently in younger patients, with the TRAM/DIEP flap and latissimus dorsi reconstruction being the most common technique.

Introduction

Breast conserving therapy aims to remove cancer while preserving aesthetic appearance and reducing risk of recurrence.[1] Oncoplastic reduction techniques are a subset of breast conserving therapy combining tumor removal with mastopexy or breast reduction techniques.[2] The goal of this approach is to avoid mastectomy while maintaining shape, symmetry, and aesthetic appearance.[3] Oncoplastic reductions are particularly suited for women with breast cancer who have large or ptotic breasts. Patients with larger breasts often have poor results with lumpectomy alone and present challenging cases for reconstruction following skin sparing mastectomy (SSM). Compared with SSM and immediate reconstruction, a reduction mammaplasty at the time of lumpectomy leads to better aesthetic and functional results in larger breasts.[4,5] The oncoplastic reduction technique also has improved margin control, with fewer surgical re-excisions, and wider margins.[6] Furthermore, the oncoplastic approach is associated with fewer breast complications and increased patient satisfaction.[7,8] Finally, this technique has been shown to reduce the need for completion mastectomy (CM) compared with lumpectomy alone, likely due to the benefit of generous resections.[4,9]

However, although the goal is to minimize additional or extensive surgical procedures in higher risk patients, unfortunately there are some instances when CM is required, often necessitating definitive postmastectomy reconstruction with its associated disadvantages. A recent systematic review of oncoplastic breast surgery showed a reoperation rate of between 14% and 49%,[10] with 7%–22% of patients having surgery for positive margins, 3%–16% having CM, and 4%–9% having reoperation for complications.[11] Despite re-excision rates being lower in the oncoplastic cohorts, it is often felt that following the more generous oncoplastic resection, if margins are positive, the tumor biology has dictated that patients are more likely to undergo CM compared with re-excision. The goal of this review was to determine the incidence and indications for CM in these patients and to evaluate the reconstructive options available, factors contributing to reconstruction at the time of CM, and outcomes.

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