Breast reconstruction in the high-risk population: current review of the literature and practice guidelines

Abstract

Breast reconstruction is an important part of the cancer treatment paradigm and the psychosocial benefits are well described in the literature. Notably, breast reconstruction restores both the functional and emotional losses patients experience due to tumor resection. Post-cancer quality of life is an important benchmark of successful treatment; therefore, breast reconstruction is an essential component that should be offered whenever possible. Over time, reconstructive techniques and outcomes have improved dramatically resulting in better patient safety and decreased operative morbidity. When counseling a patient for surgery, the provider must consider all aspects of a patient's health. Ideally, breast cancer patients should be physically, emotionally, and oncologically appropriate candidates for reconstruction. However, in concerted effort to provide opportunities for as many patients as possible, the definition of who is a good candidate for reconstruction has evolved to include higher risk patients. These patients include those with advanced age, nicotine use, obesity, and significant ptosis. With improvements in surgical procedures and perioperative care, this population may also benefit from restorative surgery. However, the exact risk of complications and necessary counseling has gone largely undefined in this population. This article examines particular "highrisk" groups that may be challenging for extirpative and reconstructive surgeons and offers current guidelines for practice.

Breast reconstruction after mastectomy in patients with obesity: a narrative review

“…showed that patients with obesity who pursued an implant-based reconstruction are significantly less satisfied with the ultimate aesthetic outcome compared to those who underwent an autologous reconstruction ( 28 ). This may be due to the limitation of implant volumes when attempting to match the mastectomy volume, leading to greater long-term satisfaction with autologous reconstruction compared to implants ( 30 ). Another study considering BREAST-Q results from 404 patients found that patient-reported physical well-being of the abdomen was lower in patients with obesity compared to non-obese patients 3 years following autologous breast reconstruction with abdominal free-tissue transfer (P<0.05) ( 27 ).…”

“…Unlike in subpectoral reconstruction, prepectoral placement necessitates use of acellular dermal matrix (ADM). The reliance of ADM in prepectoral reconstruction, while largely advantageous ( 52 - 54 ), raises concerns for ADM non-integration when used in larger quantities, as well as increased risk of complications such as seroma ( 30 , 51 , 55 ). Prepectoral breast reconstruction has been shown to have the same rate of skin necrosis (3.5%), wound dehiscence (5.9%), seroma rate (4.7%), and failure rate (1.2%) in patients with obesity compared to nonobese patients ( 56 ).…”