Houvenaeghel G; Bannier M; Van Troy A; Rua S; Barrou J; Heinemann M; Buttarelli M; Jauffret Fara C; Lambaudie E; Cohen M

Special Article – Robotic Surgery

Austin J Surg. 2019; 6(23): 1224.

Mastectomy with Immediate Breast Reconstruction with or without Robotic Surgery: Results of 310 Consecutive Patients in 2-Years

Houvenaeghel G¹*, Bannier M², Van Troy A², Rua S², Barrou J², Heinemann M¹, Buttarelli M², Jauffret Fara C², Lambaudie E¹ and Cohen M²

¹Department of surgical oncology, Paoli Calmettes Institute and CRCM, CNRS, INSERM, Aix Marseille Universitey, France

²Department of surgical oncology, Paoli Calmettes Institute, France

*Corresponding author: Gilles Houvenaeghe, Department of surgicaloncology, Paoli Calmettes Institute and CRCM, CNRS, INSERM, Aix Marseille University, France

Received: September 03, 2019; Accepted: October 24, 2019; Published: October 31, 2019

Abstract

Background: Immediate Breast Reconstruction (IBR) is offered according to patient’s wishes, previous treatment, breast cup-size and ptosis. We analyze a 2-years’ experience of consecutive patients with IBR after Skin-Sparing- Mastectomy (SSM) or Nipple-Sparing-Mastectomy (NSM) with or without robotic procedure.

Methods: Among 854 mastectomies we performed 310 IBR (36.3%). Characteristics of patients and surgery, complication rate, time of surgery, Post- Operative Hospitalization (POH) stay were determined.

Results: NSM were realized in 112 patients (36.1%). Implant-IBR was performed for 211 patients (68.1%) and Latissimus-Dorsi-Flap (LDF) for 99 patients (31.9%): robotic-NSM in 22.3% (25/112) of NSM, robotic LDF in 60.6% (60/99). Significant factors associated with LDF-IBR were BMI 25-29.9 and ›30 (OR=2.749 and 4.027), previous radiotherapy (OR=7.313) and neoadjuvant- chemotherapy (OR=4.839). The overall complication rate was 31.9% (99/310) with 29 re-operations (9.4%). Significant factors associated with any complication were cup-size›C (OR=2.165), LDF-IBR (OR=3.990), robotic-NSM (OR=3.953). Complications rates grade 2-3-4 were: 10.3% (32/310) for breast complications and 2.0% (2/99) for LDF. Implant loss rate was 4.6% (11/237). Significant factors associated with Grade 2-3 breast complications were robotic- NSM (OR=5.983) and tobacco (OR=2.234). Significant factors associated with POH›3-days were LDF-IBR (OR=21.77) and mastectomy for ipsilateral-localrecurrence (OR=5.786). Significant factors associated with time of surgery ›180mn were cup-size›C (OR=3.581), LDF-IBR (OR=779) and bilateral mastectomy (OR=9.335).

Conclusion: We reported a high rate of IBR and NSM and an increase of LDF reconstruction. IBR for ipsilateral -local-recurrence with LDF was the preferred procedure. Robotic-LDF reconstruction without dorsal scar was realized in 60.6% of patients with a low complication rate.

Keywords: Immediate breast reconstruction; Breast cancer; Robotic surgery; Mastectomy

Abbreviations

IBR: Immediate Breast Reconstruction; SSM: Skin-Sparing- Mastectomy; NSM: Nipple-Sparing-Mastectomy; POH: Post- Operative Hospitalization; LDF: Latissimus-Dorsi-Flap; BC: Breast Cancer; NAC: Neo-Adjuvant Chemotherapy; ILBCR: Ipsilateral Local BC-Recurrence; BMI: Body Mass Index; PMRT: Post Mastectomy Radiotherapy; ALND: Axillary Lymph Node Dissection; DCIS: Ductal Carcinoma In Situ; DIEP: Deep Inferior Epigastric Perforator; TRAM: Transverse Rectus Abdominis Musculocutaneous; ERAS: Enhanced Recovery After Surgery.

Introduction

Mastectomy with Immediate Breast Reconstruction (IBR) is a surgical strategy in Breast Cancer (BC) when breast-conserving surgery is not an option. This treatment strategy is also increasingly being used after Neo-Adjuvant Chemotherapy (NAC). In Skin- Sparing Mastectomy (SSM) the gland is removed and the whole breast skin is preserved. In Nipple-Sparing Mastectomy (NSM), the Nipple-Areolar Complex (NACx) is preserved as well as the skin. These conservative mastectomies are associated with superior aesthetic outcomes and patient satisfaction compared to nonconservative mastectomy. In a recent French large prospective study, satisfaction with the cosmetic outcome strongly influenced quality of life and an unsatisfactory outcome after IBR was still considered a better condition than simple mastectomy [1]. However, potential disadvantages include residual breast tissue under NACx or under the skin flaps and an increased risk of mastectomy skin flap or NAC necrosis [2].

In the US, variable rates of breast reconstruction were reported, depending a great deal on where patients lived, what kind of health insurance they had, how much money they made, and her race/ ethnicity [3]. In France, all reconstruction fees can be without financial charge for patients. Reconstruction with implant or Latissimus Dorsi- Flap (LDF) is usually proposed according to patient’s wishes, previous treatment, breast cup-size and ptosis. Moreover, since a few years’ robotic mastectomy and or robotic LDF-IBR has been proposed [4- 10]. The purpose of this study was to analyze a 2-year experience of consecutive patients with IBR after SSM or NSM with or without robotic procedure. The main aim of this study was feasibility and complications rates.

Materials & Methods

During 2-years (2016-17), 854 mastectomies were performed, including 310 with IBR (36.3%): 229 IBR among 690 mastectomies for primary BC (33.2%), 45 IBR among 126 mastectomies for ipsilateral local BC-recurrence (ILBCR) (35.7%) and 36 IBR for prophylactic mastectomy. For primary BC, 30 IBR were performed among 144 patients after NAC (20.8%) and 199 IBR among 546 patients without NAC (36.4%). This present study report retrospective analysis of 310 patients with IBR from institutional BC data base with distinction between robotic or non-robotic surgery. A program of robotic breast surgery has been started in February 2016 [11]. All patients were informed of robotic assistance surgery. Our institutional ethical committee approved robotic breast surgery procedures.

NSM had been undertaken for prophylactic mastectomy and for BC with a minimal 2 centimeters tumor-nipple distance on mammography and or MRI. Robotic muscular latissimus flap without skin-island was used for NSM and for SSM or wise pattern skin reducing mastectomy in order to avoid dorsal scar after patient’s information and choice. Robotics surgeries were achieved by two surgeons and the determination between robotic assisted or conventional surgery was in relation with availability of robotic operative room and choice of surgeon. Allocation of breast reconstruction operation type was depending patient’s wishes and surgeon’s choice in relation with breast volume and ptosis. We define autologous LDF or muscular latissimus flap as muscular flap harvested with fat around muscle and non-autologous LDF when fat around muscle was not harvested. At the end of robotic NSM, a biopsy of retro NACx tissue was performed and complete gland removal verification through axillar incision was systematically achieved [11].

Characteristics of patients and surgery were determined by age, BMI, indication of mastectomy, bilateral mastectomy, type of IBR and mastectomy, axillary surgery, ASA status, year of surgery, previous radiotherapy, NAC, previous conservative ipsilateral surgery, breast cup-size, mastectomy weight, tobacco use, diabetes, robotic mastectomy and/or robotic LDF (DaVinci SI or XI), bilateral mastectomy, Post-Operative Hospitalization (POH) stay, time of anesthesia and surgery. Breast cup-size had been compared with mastectomy weight in order to validate this qualitative criterion. Complication rate was analyzed with Clavien-Dindo grading [12] for all patients, for breast complications and for dorsal complications respectively. Grade 3 corresponded to any complication which requires re-operation and Grade 4 corresponded to severe general infection. Grade 1 or 2 complications corresponded to infection or dehiscence or hematoma or bleeding or skin necrosis but without necessity of re-operation.

The duration of anesthesia was recorded from anesthesia induction to tracheal extubation including pectoral bloc local anesthesia and the duration of surgery included all procedures and the times for changing surgical postures, from skin incision to the end of skin suture. The number of POH days was reported from day of surgery to discharge. Interval-time between surgery and adjuvant chemotherapy and or Post Mastectomy Radiotherapy (PMRT) was analyzed.

Statistics

Quantitative criteria were analyzed with median, mean, CI 95% and range. Comparisons were determined using Chi2-test for qualitative criteria and t-test for quantitative criteria. Binary logistic regression was used to determined independent significant criteria. Analysis was evaluated per patient number. P-value ‹= 0.05 was considered as significant.

Results

During 2-years (2016-17), 310 patients were operated (331 IBR with 21 bilateral IBR): 229 (73.9%) for primary BC, 45 (14.5%) for ILBCR and 36 (11.6%) for prophylactic mastectomy, with 112 NSM (36.1%), 197 SSM (63.5%) and 1 standard mastectomy (0.3%). NSM were achieved in 27.9% for primary BC (64/229) (57/199: 28.6% without NAC and 7/30: 23.3% with NAC), 44.4% for ILBCR (20/45) and 77.8% for prophylactic mastectomy (28/36) (Table 1). For patients with bilateral mastectomy (15 NSM and 6 SSM), IBR were performed with definitive implant in 20 cases and expander implant in 1 patient. Breast cup-size was significantly correlated with mastectomy weight.

Table 1: Characteristics of patients according to Skin Sparing Mastectomy (SSM) or Nipple Sparing Mastectomy (NSM) and according to robotic or non-robotic surgery.




  
    
    
    All patients
    SSM
      Nb 
    %
    NSM
      Nb 
    %
    Chi²
      p 
    Non-Robotic
    Robotic
    Chi²
      p 
  
  
    Nb
    %
    Nb
    %
  
  
    All patients
    
    310
    198
    63.9
    112
    36.1
    
    243
    
    67
    
    
  
  
    Mastectomy
    SSM
    
    198
    
    
    
    
    170
    70.0
    28
    41.8
    <0.0001
  
  
    NSM
    
    
    
    112
    
    
    73
    30.0
    39*
    58.2
  
  
    Bilateralmastectomy
    
    21
    6
    3.0
    15
    13.4
    0.001
    21
    8.6
    0
    0
    0.005
  
  
    Implant
    definitive
    169
    94
    47.5
    75
    67.0
    <0.001
    162
    66.7
    7
    10.4
    <0.0001
  
  
    expander
    42
    40
    20.2
    2
    1.8
    
    42
    17.3
    0
    0
    
  
  
    LDF
    autologous
    68
    47
    23.7
    21
    18.7
    
    36
    14.8
    32
    47.8
    
  
  
    non-autologous
    5
    1
    0.5
    4
    3.6
    
    1
    0.4
    4
    6.0
    
  
  
    
    with    implant
    26
    16
    8.1
    10
    8.9
    
    2
    0.8
    24
    35.8
    
  
  
    Indication
    breast    cancer
    229
    165
    83.3
    64
    57.1
    <0.0001
    184
    75.7
    45
    67.2
    <0.0001
  
  
    local    recurrence
    45
    25
    12.6
    20
    17.9
    
    24
    9.9
    21
    31.3
    
  
  
    prophylactic
    36
    8
    4.0
    28
    25.0
    
    35
    14.4
    1
    1.5
    
  
  
    Previous    radiotherapy
    No
    243
    156
    78.8
    87
    77.7
    0.463
    206
    84.8
    37
    55.2
    <0.0001
  
  
    Yes
    67
    42
    21.2
    25
    22.3
    
    37
    15.2
    30
    44.8
    
  
  
    Chemotherapy
    No
    204
    128
    64.7
    76
    67.9
    0.80
    168
    69.1
    36
    53.7
    0.03
  
  
    Adjuvant
    71
    47
    23.7
    24
    21.4
    
    53
    21.8
    18
    26.9
    
  
  
    Neo-adjuvant
    35
    23
    11.6
    12
    10.7
    
    22
    9.1
    13
    19.4
    
  
  
    Axillarysurgery
    No
    131
    67
    33.8
    64
    57.1
    <0.001
    99
    40.7
    32
    47.8
    0.005
  
  
    SLNB
    146
    106
    53.5
    40
    35.7
    
    124
    51.0
    22
    32.8
    
  
  
    ALND
    33
    25
    12.6
    8
    7.1
    
    20
    8.2
    13
    19.4



Table 1: Characteristics of patients according to Skin Sparing Mastectomy (SSM) or Nipple Sparing Mastectomy (NSM) and according to robotic or non-robotic surgery.

Table 1 of 1:




  
    Year of    surgery
    2016
    143
    84
    42.4
    59
    52.7
    0.053
    124
    51.0
    19
    28.4
    0.001
  
  
    2017
    167
    114
    57.6
    53
    47.3
    
    119
    49.0
    48
    71.6
    
  
  
    ASA    status
    1
    141
    90
    45.4
    51
    45.5
    0.471
    114
    46.9
    27
    40.3
    0.520
  
  
    2
    162
    102
    51.6
    60
    53.6
    
    123
    50.6
    39
    58.2
    
  
  
    3
    7
    6
    3.0
    1
    0.9
    
    6
    2.5
    1
    1.5
    
  
  
    Previous    BCS
    No
    189
    115
    58.1
    74
    66.1
    0.103
    156
    64.2
    33
    49.3
    0.019
  
  
    Yes
    121
    83
    41.9
    38
    33.9
    
    87
    35.8
    34
    50.7
    
  
  
    Tobacco
    No
    251
    163
    82.3
    88
    78.6
    0.254
    200
    82.3
    51
    76.1
    0.167
  
  
    Yes
    59
    35
    17.7
    24
    21.4
    
    43
    17.7
    16
    23.9
    
  
  
    BMI
    < 24.9
    240
    143
    72.2

    97
    86.6
    0.014
    194
    79.8
    46
    68.7
    0.108
  
  
    25-29.9
    54
    42
    21.2
    12
    10.7
    
    39
    16.0
    15
    22.4
    
  
  
    > 30
    16
    13
    6.6
    3
    2.7
    
    10
    4.1
    6
    9.0
    
  
  
    POH
    < 3days
    227
    147
    74.2
    80
    71.4
    0.341
    203
    83.5
    24
    35.8
    <0.0001
  
  
    > 3days
    83
    51
    25.8
    32
    28.6
    
    40
    16.5
    43
    64.2
    
  
  
    mastectomyweight
    < 300gr
    153
    83
    41.9
    70
    62.5
    <0.0001
    121
    49.8
    32
    47.8
    0.438
  
  
    >    300gr
    157
    115
    58.1
    42
    37.5
    
    122
    50.2
    35
    52.2
    
  
  
    Histology
    DCIS
    72
    54
    27.3
    18
    16.1
    <0.0001
    60
    24.7
    12
    17.9
    0.004
  
  
    invasive
    201
    136
    68.7
    65
    58.0
    
    147
    60.5
    54
    80.6
    
  
  
    benign
    37
    8
    4.0
    29
    25.9
    
    36
    14.8
    1
    1.5
    
  
  
    Syntheticmesh
    
    7
    3
    1.5
    4
    3.6
    
    7
    2.9
    0
    0
    
  
  
    Cup    size
    < C
    264
    163
    82.3
    101
    90.2
    0.042
    207
    85.2
    57
    85.1
    0.558
  
  
    > C
    46
    35
    17.7
    11
    9.8
    
    36
    14.8
    10
    14.9
    
  
  
    SSM:    Skin Sparing Mastectomy; NSM: Nipple Sparing Mastectomy; LDF: Latissimus    Dorsi-Flap; SLNB: Sentinel Lymph Node Biopsy; ALND: Axillary Lymph Node    Dissection; BCS: Breast Conservative Surgery; BMI: Body Mass Index; POH: Post-Operative    Hospitalization; DCIS: Ductal Carcinoma in Situ



Table 1 of 1:

For patients with breast implant alone or in association with LDF, we realized a nasal research of staphylococcus germ and pre-operative antimicrobial therapy for patients with potage germs. Then, peroperative antimicrobial-prophylaxis was systematically performed for all patients with IBR.

Robotic NSM was achieved in 22.3% (25/112) of NSM, robotic dorsi-flap in 60.6% (60/99) including 18 patients with robotic-NSM and robotic LDF-IBR. All robotic procedures were performed by two surgeons: 67 robotic procedures among 133 surgeries (50.4%), 25 robotic-NSM among 61 NSM (41.0%) and 60robotic-LDF-IBR among 62 dorsi-flap (96.8%). For SSM, robotic-LDF was harvested through incision of NACx resection. For robotic-NSM, we used short axillar incisions for mastectomy and LDF dissection.

Previous radiotherapy was reported in 67 cases (67/274 IBR for BC: 24.4%): 44 patients with ILBCR (1 patient without previous radiotherapy), 22 patients with previous chemotherapy and radiotherapy before mastectomy with IBR using dorsi-flap [13,14] and 1 patient with complementary mastectomy for BRCA mutation after NAC and radiotherapy.

Type of IBR

Implant-IBR were achieved for 211 patients (68.1%), including 19.9% with expander implants (42/211) and LDF for 99 patients (31.9%) with 76 autologous-LDF (8 associated with implant), 5 nonautologous- LDF without implant and 18 non-autologous dorsi-flap with implant (Table 2). A titanium-coated polypropylene mesh, specifically TiLoop^® Bra (TiLOOP^® Bra, pfm medical, Cologne, Germany) was used in 7 patients among 169 definitive implant-IBR (4.1%), for 2 patients with cup-size C and 3with cup-size ›C, without PMRT and with previous radiotherapy in 2 cases.

Table 2: Characteristics of patients according to type of Immediate Breast Reconstruction (IBR).




  
    
    
    Implant/Expander
    LDF
    LDF + implant
    Chi²
      p 
  
  
    Nb
    %
    Nb
    %
    Nb
    %
  
  
    All patients
    
    211
    68.1
    73
    23.5
    26
    8.4
    
  
  
    Mastectomy
    SSM
    134
    63.5
    48
    65.8
    16
    61.5
    0.911
  
  
    NSM
    77
    36.5
    25
    34.2
    10
    38.5
    
  
  
    Bilateralmastectomy
    
    21
    10.0
    0
    
    0
    
    0.005
  
  
    Indication
    breast cancer
    159
    75.4
    52
    71.2
    18
    69.2
    <0.0001
  
  
    local recurrence
    16
    7.6
    21
    28.8
    8
    30.8
    
  
  
    prophylactic
    36
    17.1
    0
    
    0
    
    
  
  
    Previousradiotherapy
    No
    195
    92.4
    39
    53.4
    9
    34.6
    <0.0001
  
  
    Yes
    16
    7.6
    34
    46.6
    17
    65.4
    
  
  
    Chemotherapy
    No
    154
    73.0
    40
    54.8
    10
    38.5
    <0.0001
  
  
    Adjuvant
    48
    22.7
    19
    26.0
    4
    15.4
    
  
  
    Neo-adjuvant
    9
    4.3
    14
    19.2
    12
    46.1
    
  
  
    Axillarysurgery
    No
    81
    38.4
    36
    49.3
    14
    53.8
    <0.001
  
  
    SLNB
    117
    55.4
    25
    34.2
    4
    15.4
    
  
  
    ALND
    13
    6.2
    12
    16.4
    8
    30.8
    
  
  
    Year of surgery
    2016
    102
    48.3
    29
    39.7
    12
    46.2
    0.445
  
  
    2017
    109
    51.7
    44
    60.3
    14
    53.8
    
  
  
    ASA status
    1
    102
    48.3
    28
    38.4
    11
    42.3
    0.550
  
  
    2
    104
    49.3
    43
    58.9
    15
    57.7
    
  
  
    3
    5
    2.4
    2
    2.7
    0
    0
    
  
  
    Previous BCS
    No
    144
    68.2
    34
    46.6
    11
    42.3
    0.001
  
  
    Yes
    67
    31.8
    39
    53.4
    15
    57.7
    
  
  
    Tobacco
    No
    176
    83.4
    56
    76.7
    19
    73.1
    0.256
  
  
    Yes
    35
    16.6
    17
    23.3
    7
    26.9
    
  
  
    BMI
    < 24.9
    173
    82.0
    52
    71.2
    15
    57.7
    0.030
  
  
    
    25-29.9
    30
    14.2
    15
    20.5
    9
    34.6
    
  
  
    > 30
    8
    3.8
    6
    8.2
    2
    7.7
    
  
  
    POH
    < 3days
    194
    91.9
    29
    39.7
    4
    15.4
    <0.0001
  
  
    > 3days
    17
    8.1
    44
    60.3
    22
    84.6
    
  
  
    Mastectomy weight
    < 300gr
    106
    50.2
    41
    56.2
    6
    23.1
    0.014
  
  
    > 300gr
    105
    49.8
    32
    43.8
    20
    76.9
    
  
  
    Histology
    DCIS
    56
    26.5
    12
    16.4
    4
    15.4
    <0.0001
  
  
    invasive
    119
    56.4
    60
    82.2
    22
    84.6
    
  
  
    benign
    36
    17.1
    1
    1.4
    0
    0
    
  
  
    Syntheticmesh
    
    7
    100
    0
    
    0
    
    
  
  
    Cup size
    < C
    180
    85.3
    67
    91.8
    17
    65.4
    0.005
  
  
    > C
    31
    14.7
    6
    8.2
    9
    34.6
    
  
  
    SSM: Skin Sparing Mastectomy; NSM: Nipple Sparing    Mastectomy; LDF: Latissimus Dorsi-Flap; SLNB: Sentinel Lymph Node Biopsy;    ALND: Axillary Lymph Node Dissection; BCS: Breast Conservative Surgery; BMI: Body    Mass Index; POH: Post-Operative Hospitalization; DCIS: Ductal Carcinoma in    Situ



Table 2: Characteristics of patients according to type of Immediate Breast Reconstruction (IBR).

Median implant-size was 292cc (mean=294, CI 95%=281-306, range=100-510), 290cc for implant-IBR (mean=287, CI 95%=275- 300, range=100-510) and 340cc for combined implant and LDF-IBR (mean=333, CI 95%=297-369, range=105-490).

In univariate analysis, significant criteria associated with IBR using implant or LDF were BMI, ALND, previous radiotherapy, NAC, previous conservative ipsilateral surgery, indication of mastectomy and robotic-mastectomy. In multivariate analysis, adjusted on BMI (‹24.9, 25-29.9, ›30), previous radiotherapy, NAC and previous conservative ipsilateral surgery, significant factors associated with LDF-IBR were BMI 25-29.9 and ›30 (Odds ratios=2.749 and 4.027, CI 95%=1.34-5.63 and 1.26-12.9, p=0.006 and 0.019, respectively), previous radiotherapy (OR=7.313, CI 95%=3.43-15.6, p‹0.0001), NAC (OR=4.839, CI 95%=1.84-12.7, p=0.001).

Complications

The overall complication rate was 31.9% (99/310) with 29 reoperations (29/310: 9.4%). Grades of complications are reported in (Table 3): two grades 3 LDF complications were observed with reoperation for bleeding. All others LDF complications were dorsal seroma, which needed evacuation. Any muscle necrosis occurred. Five patients have diabetes (1.6%) which required treatment and complication rates were not different between patients with diabetes (3/5: 60.0%) in comparison with patients without diabetes (96/305: 31.5%) (p=0.188).

Table 3: Complications and grade Clavien Dindo.




  
    
    No
    Grade 1
    Grade 2
    Grade 3
    Grade 4
  
  
    Nb
    %
    Nb
    %
    Nb
    %
    Nb
    %
    Nb
    %
  
  
    Breast
    239
    77.1
    39
    12.6
    5
    1.6
    26
    8.4
    1
    0.3
  
  
    Dorsal    (n=99)
    58
    58.6
    39
    39.4
    0
    0
    2
    2.0
    0
    0
  
  
    Breast &    Dorsal
    211
    68.1
    65
    21.0
    5
    1.6
    28
    9.0
    1
    0.3
  
  
    Breast    complication
    
    
    
    
    
    
    
    
    
    
  
  
    Implant
    167
    79.1
    23
    10.9
    1
    0.5
    19
    9.0
    1
    0.5
  
  
    LDF
    55
    75.3
    11
    15.1
    4
    5.6
    3
    4.1
    0
    
  
  
    LDF + implant
    17
    65.4
    5
    19.2
    0
    
    4
    15.4
    0
    
  
  
    LDF complication
    
    
    
    
    
    
    
    
    
    
  
  
    Robotic    LDF
    34
    56.7
    25
    41.7
    0
    
    1
    1.7
    0
    
  
  
    non-robotic    LDF
    24
    61.5
    14
    35.9
    0
    
    1
    2.6
    0
    
  
  
    LDF:    Latissimus Dorsi-Flap



Table 3: Complications and grade Clavien Dindo.

In univariate analysis, significant criteria associated with any complications were ALND, previous radiotherapy, tobacco, cup-size, IBR with implant versus dorsi-flap and robotic versus conventional mastectomy. There were no significant difference between autologous and non-autologous LDF-IBR (39/76: 51.3% versus 16/23: 69.6%, respectively, p=0.095), between definitive-implant versus expanderimplant (31/169: 18.3% versus 13/42: 31.0%, p=0.060) and between LDF-IBR versus LDF with breast-implant (39/73: 53.4% versus 16/26: 61.5%, p=0.45). There were no significant difference between NSM and SSM (39/112: 34.8% versus 60/198: 30.3%, p=0.244) but significant difference for NSM with or without robotic assistance (17/25: 68.0% versus 22/87: 25.3%, p‹0.0001). In multivariate analysis, adjusted on previous radiotherapy, ALND, tobacco, cupsize (‹C or ›C), IBR with implant or dorsi-flap, robotic-NSM, type of mastectomy, significant factors associated with any complication were cup-size ›C (OR=2.165, CI 95%=1.07-4.39, p=0.032), LDFIBR (OR=3.990, CI 95%=2.13-7.46, p‹0.0001) and robotic-NSM (OR=3.953, CI 95%=1.37-11.4, p=0.011).

Complications rates grade 2-3-4 were: 10.97% (34/310) for breast and dorsi-flap complications, 10.3% (32/310) for breast complications and 2.0% (2/99) for dorsi-flap complications. Complications rates grade 2-3-4 were: 9.6% (7/73) for muscular latissimus flap without implant, 15.4% (4/26) for muscular latissimus flap with implant, 9.5% (16/169) for definitive-implant and 11.9% (5/42) for expander (non-significant). There was significant difference of complications rates grade 2-3 for NSM with or without robotic assistance (8/25: 32.0 versus 8/87: 9.2%, p=0.008).

In multivariate analysis, adjusted on previous radiotherapy, ALND, tobacco, cup-size (‹C or ›C), IBR with implant or dorsi-flap, robotic-NSM, type of mastectomy, significant factor associated with Grade 2-3 complications was robotic-NSM (OR=5.176, CI 95%=1.52- 17.6, p=0.008), significant factors associated with Grade 2-3 breast complications were robotic-NSM (OR=5.983, CI 95%=1.72-20.8, p=0.005) and tobacco (OR=2.234, CI 95%=0.95-5.24, p=0.065) and any factor was significantly associated with Grade 2-3 dorsal complications.

Implant loss rate was 4.6% (11/237): 8 definitive implants (8/195: 4.1%) and 3 expander implants (3/42: 7.1%) (non-significant), all without previous radiotherapy.

Post-operative hospitalization

Median POH was 2 days (mean=2.75, CI 95%=2.55-2.93, range=1-14) (Table 4). In univariate analysis, significant criteria associated with POH were ALND, LDF-IBR, indication of mastectomy, BMI, previous radiotherapy, NAC, previous conservative ipsilateral surgery, robotic-NSM. In multivariate analysis, adjusted on ALND, LDF-IBR, indication of mastectomy, BMI, previous radiotherapy, NAC, previous conservative ipsilateral surgery, robotic-NSM, significant factors associated with POH ›3-days were LDF-IBR (OR=21.77, CI 95%=9.83-48.2, p‹0.0001) and ILBCR (OR=5.786, CI 95%=1.29-25.9, p=0.022).

Table 4: Median, mean, CI 95%, range results for Post-Operative Hospitalization (POH), time of surgery and anesthesia, mastectomy weight.




  
    
    
    All patients
    t-test
  
  
    Median
    Mean
    CI95%
    range
    p
  
  
    POH
    all
    2
    2.75
    2.56-2.93
    1_14
    
  
  
    implant
    2
    2.09
    1.91-2.27
    1_14
    0.009
  
  
    LDFR
    4
    4.16
    3.89-4.44
    2_8
    
  
  
    Time of    surgery
    all
    151
    186
    175-198
    42-495
    
  
  
    implant
    118
    130
    122-137
    42-390
    <0.0001
  
  
    LDFR
    290
    304
    289-320
    158-495
    
  
  
    Time of    anesthesia
    all
    214.5
    252
    239-264
    90-575
    
  
  
    implant
    180
    192
    183-200
    90-563
    <0.0001
  
  
    LDFR
    361
    375
    359-391
    210-575
    
  
  
    Mastectomy    weight
    all
    304
    350
    327-374
    47-1500
    
  
  
    SSM
    334
    383
    351-415
    47-1500
    0.007
  
  
    NSM
    240.5
    292
    261-322
    70-819
    
  
  
    Time of    surgery
    Robotic
    304
    317
    296-338
    127-495
    0.028
  
  
    non-robotic
    127
    149
    140-158
    42-388
    
  
  
    Time of    anesthesia
    Robotic
    382
    394
    373-415
    234-575
    0.069
  
  
    non-robotic
    192
    211
    201-221
    90-447
    
  
  
    Time of    surgery
    R-LDF
    315
    326
    305-347
    190-495
    0.003
  
  
    nonR-LDF
    266
    270
    252-288
    158-388
    
  
  
    Time of    anesthesia
    R-LDF
    386
    401
    380-422
    250-575
    0.010
  
  
    Non-R-LDF
    324.5
    335
    316-353
    210-447
    
  
  
    SSM:    Skin Sparing Mastectomy; NSM: Nipple Sparing Mastectomy; LDFR: Latissimus    Dorsi-Flap Reconstruction; POH: Post-Operative Hospitalization; R-LDF: Robotic    Latissimus Dorsi-Flap



Table 4: Median, mean, CI 95%, range results for Post-Operative Hospitalization
(POH), time of surgery and anesthesia, mastectomy weight.

Time of surgery and anesthesia (Table 4)

Median time of surgery was 151mn (mean=186, CI 95%=175-198, range=42-495). In univariate analysis, significant criteria associated with time of surgery >180mn were indication of mastectomy, previous radiotherapy, NAC, previous conservative ipsilateral surgery, cupsizes, LDF-IBR, ALND (bilateral mastectomy: non-significant).In multivariate analysis, adjusted on indication of mastectomy, previous radiotherapy, NAC, previous conservative ipsilateral surgery, cupsizes, LDF-IBR, ALND and bilateral mastectomy, significant factors associated with time ›180mn were cup-size›C (OR=3.581, CI 95%=1.29-9.92, p=0.014), LDF-IBR (OR=779, CI 95%=95.7-6340, p‹0.0001) and bilateral mastectomy (OR=9.335, CI 95%=3.10-28.1, p‹0.0001).When multivariate analysis was also adjusted on roboticsurgery, robotic procedures was a significant factor associated with time ›180mn (OR=42.0, CI 95%=6.69-263, p‹0.0001).

Median time of anesthesia was 214.5mn (mean=252, CI 95%=239-264, range=90-575). In univariate analysis, significant criteria associated with time of anesthesia ›252mn were indication of mastectomy, previous radiotherapy, NAC, previous conservative ipsilateral surgery, LDF-IBR, ALND, ASA-status, robotic-NSM (bilateral mastectomy: non-significant).In multivariate analysis, adjusted on indication of mastectomy, previous radiotherapy, NAC, previous conservative ipsilateral surgery, LDF-IBR, ALND, ASAstatus and bilateral mastectomy, significant factors associated with time ›252mn were LDF-IBR (OR=270, CI 95%=69-1058, p‹0.0001) and bilateral mastectomy (OR=11.74, CI 95%=3.77-36.5, p‹0.0001). When multivariate analysis was also adjusted on robotic-surgery, robotic procedures was a significant factor associated with time ›252mn (OR=16.4, CI 95%=3.22-83.7, p=0.001).

Pathologic results, treatment and lipofilling

Median mastectomy weight were 304gr (mean=350, CI 95%=326-374, range=47-1500), 240gr (mean=292, CI 95%=261-322, range=70-819) for NSM and 334gr (mean=383, CI 95%=351-415, range=47-1500) for SSM.

Breast cancer histology were 72 DCIS, 159 ductal invasivecarcinomas, 39 lobular invasive-carcinomas, 3 others invasivecarcinomas and 37 benign tumors.

For invasive BC, adjuvant chemotherapy was done in 35.3% of patients (71/201) and endocrine therapy in 85.6% (174/201). PMRT was realized in 44 cases (30.1%) for invasive-BC (44/146): 22 patients had received radiotherapy after chemotherapy before mastectomy and 33 patients with ILBCR had received radiotherapy. Higher rates of PMRT were reported for patients with implant-IBR in comparison with LDF-IBR (31.2% vs 27.0%: 34/109 and 10/37 for invasive carcinomas). Median interval-time between surgery and adjuvant treatment when it was required (77 patients: 24.8%) was 46-days (CI 95%=47.2-57.6, range=23-167), 43-days for adjuvant chemotherapy (CI 95%=42-53, range=23-167) and 63-days for PMRT (CI 95%=59- 80, range=35-107) respectively, 45-days for patients without postoperative complications (CI 95%=44.7-56.9, range=23-167) and 51-days for patients with any complication (CI 95%=45.9-66.4, range=32-107) respectively.

Higher rate of interval time ›60-days was observed for PMRT (9/17: 52.9%) in comparison with adjuvant chemotherapy (10/60: 16.7%) (p=0.004), without significant difference between patients with or without any complication or complication Grade 2-3.

Lipofilling were performed for 49 patients to June 2018, 28 for implant-IBR (57.1%) and 21 for LDF-IBR (42.9%) with only one procedure in 82.1% of patients with implant-IBR and 42.9% of patients with LDF-IBR. Median fat injection volume was 120cc for implant-IBR (mean=182.5, CI 95%=73-291, range=10-1340) and 417.5cc (mean=384, CI 95%=297-471, range=90-680) for LDF-IBR.

Discussion

Our study includes a large amount of patients, even if it is a monocentric study. We offer various surgical techniques, even though we do not perform microsurgery, DIEP and loco-regional or perforator based flaps. The limit of our study is the lack of cosmetic assessment in association of quality of life.

Rate of NSM

We reported a high rate of NSM for BC during this recent period (30.4%: 83/273) including 23.8% of NSM for ILBCR (20/84). Autologous-IBR was the procedure preferred for patients with irradiated skin flaps (51/67: 76.1%), as reported by Berry et al., [15], associated with secondary lipofilling in order to obtain sufficient breast volume. For patients who had lipofilling before June 2018, a high fat injection volume was allowed (median=417.5cc).

Rate of robotic surgery

Robotic breast-surgery was proposed since February 2016, in 13.3% (19/143) during year-2016 and 28.7% (48/167) during year- 2017: 25robotic-NSM, 42robotic-LDF and 18robotic-NSM with concomitant robotic-LDF. Sixty-six per-cents (60/99) of LDF were performed with robotic-surgery, without any dorsal scar through axillar incision for NSM and through incision of NAC resection for SSM [4].

Only few cases were reported in literature studies for prophylactic NSM [5] or some cases of BC [8,10] and for LDF-IBR [4,9]. In relation with our beginning experience with robotic breast-surgery, we reported higher times of procedures in comparison with nonrobotic- surgery. However, with learning curve we have reported a decrease of time for these robotic procedures in previous studies [11] as reported by Lai et al., [10].

Rate of LDF

IBR was realized with LDF in 31.9% of patients (99/310) including 64.4% (29/45) of LDF-IBR for ILBCR and 76.1% (51/67) of IBR after previous radiotherapy for ILBCR or mastectomy after chemotherapy and radiotherapy. Consequently, LDF-IBR for primary BC was 23.2% (48/207). An implant was associated with LDF for 26 patients (26.3%) with cup-size >C in 9 cases and mastectomy weight >300gr in 20 cases. We reported an increase of LDF-IBR in year 2017 in comparison with 2016 (41/102: 40.2% vs 58/109: 53.2%). In our study, factors significantly associated with LDF-IBR were high BMI and previous radiotherapy and/or NAC. All IBR for bilateral mastectomy were performed with implant.

Complications

The overall complication rate was 31.9%, quite similar with others studies: 49% in Pinsolle et al study [16] with 266 IBR, 45% in the prospective study reported by Alderman et al., [17] with 326 IBR mainly with TRAM (76%), 31.8% in Berry et al study [15] with 1037 IBR, 62% in Contant et al., study [18] and 55% in Ducic et al., study for TRAM-IBR [19]. However, complications rates are difficult to compare with others studies in reason with great disparities of IBR types, complications recorded, different indications of mastectomy and time of survey.

In recent studies with IBR and NSM, complications rates reported was lesser: 5.1% (6/117) in Corso et al., study [20], 18% for NSM (40/219) in Romanoff et al., study [21], 20% in Headon et al., [22] pooled analysis of 12,358 NSM with a nipple necrosis rate of 5.9%. In a recent review of 3716 prophylactic-NSM [23] the average overall complication rate was 20.5%, the average NACx necrosis was 8.1% and 7.1% for the cutaneous skin flaps.

Even use of pre-operative antimicrobial therapy for patients with nasal-germs and per-operative antimicrobial-prophylaxis we reported a 4.1% rate of implant loss mainly in relation with infectious complication. However, this rate was lesser than rates reported by others [16,17].

In our study, overall complication rate was lesser for LDF-IBR (24.7%) and implant-IBR (20.9%) than LDF with implant-IBR (34.6%) but non-significant. However, in a retrospective study with 12,129 patients operated between 2005-2011, autologous-flap-IBR was associated with higher complication rate in comparison with breast-implant-IBR (OR=1.41 in multivariate analysis) [24]. Dorsal seroma rate was 39.4% similar to the rate of 35% reported by Pinsolle et al., [16].

Major complications rate, grade 3-4 with re-operation and/or rehospitalization, was 9.35% (29/310) in our study, lesser than reported rates in others studies (11-37%) [17,18,25-27] but with different IBR procedures, different criteria of complications recorded and different time of survey in reported studies. Except 2 cases of re-operation for dorsal bleeding, all 27 grade 3-4 complications were in relation with mastectomy. In the large NMBRA-cohort [28] with 3389 IBR this rate was 15.8% with 3-months of follow-up. Grade 2-3-4 complications rate were 10% for implant-IBR, 9.7% for LDF-IBR and 15.4% for LDF with implant-IBR (non-significant) in our study.

Complications and previous radiotherapy: In our study, 76.1% of patients had LDF-IBR with or without implant. Complications rate were 20.9% for implant-IBR (44/211) and 55.6% for LDF-IBR (55/99). In multivariate analysis, previous radiotherapy was not-significantly associated with overall complication and Grade 2-3-4 complications. However, Krueger et al., [29] reported higher complication rate with previous radiotherapy in comparison with no radiotherapy for implant-IBR (68% vs 31%; p=0.006) and Berry et al., [15] reported higher major-complication rate (OR=2.7 [1.5 - 4.9]) with previous radiotherapy, with lesser complications for flap-IBR in comparison with implant-IBR (p=0,005; OR=0.22).

Complications and tobacco: In our study, Grade 2-3- 4 complication rate was significantly associated with tobacco (OR=2.234). Two studies reported higher failure IBR rate for patients with tobacco use [30,31]. The risk of flap necrosis was increase by tobacco [32-34] and infection rate was also increase in several studies [19,31,34].

Complications, time of surgery, anesthesia and robotic surgery: Overall complication rates for LDF-IBR, robotic or non-robotic were not-significantly different (26/60: 43.3% versus 15/39: 38.5%) and grade 3 complication rates were also not different (1.7% versus 2.6%). In multivariate analysis, time of surgery and anesthesia were higher for robotic procedures in comparison with non-robotic procedures. We observed in other study a decrease of time of anesthesia and surgery according to learning curve [11] and we hope that increase experience of robotic breast-surgery allowed non-significant times of procedures in the next years.

Post-operative hospitalization: In our study median POH was low (2 days, mean: 2.75) with significant higher POH for patients with LDF-IBR and IBR for ILBCR in multivariate analysis. In Offodile et al., study [35], Enhanced Recovery After Surgery (ERAS) significantly reduces length of stay (-1.58, p‹0.00001) in comparison with traditional care. However, length of stay in eight studies with 1151 patients was higher, even for ERAS (1 to 6.2 mean days, › 3 days for 5 studies). Complications rates were not different between ERAS and traditional care, but ERAS significantly reduces opioid use. We think that ERAS for IBR could be contributive for lesser length of stay, particularly for flap-IBR, for pain control and quicker recovery. In our practice, opioid use was also decrease in relation with local anesthesia before incision (paravertebral bloc or pectoral bloc). We have started an ERAS program from several years for colo-rectal, urologic and gynecologic oncological surgery in our institution and planed an ERAS program for IBR in next months.

Interval time between surgery and adjuvant chemotherapy or PMRT was not different for patients with or without post-operative complications. IBR seems not to be a reason for delayed adjuvant treatment.

Conclusion

We reported a high rate of IBR for primary BC and ILBCR with a high rate of NSM (36.1%) and an increase of LDF-IBR in year 2017 in comparison with 2016 (41/102: 40.2% vs 58/109: 53.2%). LDF-IBR for ILBCR was the preferred procedure, realized in 64.4% of cases. Robotic LDF-IBR without dorsal scar was realized in 60.6% (60/99) of patients with a low complication rate.

We reported short post-operative hospitalization stay (median: 2 days) but we think that ERAS program could decreased this length of stay. We hope to confirm these results with practice evolution analysis during year-2018.

References

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Citation: Houvenaeghel G, Bannier M, Van Troy A, Rua S, Barrou J, Heinemann M, et al. Mastectomy with Immediate Breast Reconstruction with or without Robotic Surgery: Results of 310 Consecutive Patients in 2-Years. Austin J Surg. 2019; 6(23): 1224.

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