What is the role of a transposition flap in delayed breast reconstruction with an implant?
Consider the use of a transposition flap in case of delayed breast reconstruction with an implant.
Always use a transposition flap in case of delayed breast reconstruction with an implant following previous radiation therapy.
Historically, all breast reconstructions were delayed for months to even years due to worries about compromising adjuvant therapy or masking potential local recurrence (Noone et al, 1982; Kroll et al, 1991). The explicit confrontation with the loss of a breast and acceptance of this loss was even considered a psychological advantage for the woman (Rosate et al, 1980). Delayed reconstruction often means multiple surgeries are required to reconstruct the breast. The amount of remaining skin is often insufficient and must either be stretched or supplemented with additional tissue. It is unclear which of these two strategies is preferred for a delayed breast reconstruction.
Aesthetic result, postoperative complications, quality of life and local control.
There are no studies which compared the effect of delayed reconstruction using a tissue expander followed by a definite prosthesis with a delayed reconstruction using a local transposition flap to cover the implant on the aesthetic result, postoperative complications, quality of life and local control.
The working group found no comparative studies answering this question.
Search and select
In order to answer the primary question, a systematic literature review was performed for the following question:
What is the effect of delayed reconstruction with a tissue expander followed by a definite prosthesis on the aesthetic result, postoperative complications, quality of life and local control compared to delayed reconstruction with an implant and addition of a local transposition flap?
Search and selection (Method)
See primary module: What is the role of implants in immediate breast reconstruction?.
Immediate breast reconstruction usually does not require additional skin flaps and often requires fewer surgeries. The cosmetic result is generally superior, because the skin envelope of the breast can be spared and volume replacement is the primary concern. It results in a small amount of added morbidity, with a shorter admission duration and can be performed in almost anyone (Christensen et al, 2011).
A high likelihood of postoperative radiation therapy can be a reason to delay reconstruction. Delaying reconstruction may also be a better option for a patient at higher risk of complications due to body weight, lifestyle or comorbidity. It is often worthwhile to advice such a patient to cease smoking for example in order to reduce this risk. Delaying reconstruction due to the lack of combined availability of a surgical oncologist and plastic surgeon is not a justifiable reason. Delay due to treatment of disseminated disease is under debate. However, delaying reconstruction may be the patient’s explicit wish.
Indirect arguments for adding a transposition flap without prior radiation therapy.
For delayed breast reconstruction, it is theoretically possible to only use an implant. However, the risk of complications such as infection, seroma, implant loss along with capsular contracture, asymmetry and displacement of the implant is extremely high. Even if no radiation therapy is given. Hvilsom et al (2011) reported a 10-year risk of 68% for all complications combined, with a 33% chance of displacement or asymmetry of the implant and about a 40% risk of repeat surgery. If a delayed reconstruction is performed using only an implant, this substantial risk of repeat surgery will have to be taken into consideration.
Direct arguments for adding a transposition flap after prior radiation therapy.
A delayed reconstruction using only an implant after prior radiation therapy entails an even greater risk of capsular contracture and repeat surgery. The chance of a failed reconstruction is also high: 13.2% (Hvilsom et al, 2012) to 40% (Hirsch et al, 2012). Chang et al (2008) compared 776 implant reconstructions with 146 latissimus dorsi with implant reconstructions (follow-up 7-216 months) and analyzed the effect of radiation therapy before and after reconstruction. They found a clearly elevated risk of implant complications and failure for the delayed implant reconstruction if preceded by radiation therapy (42.4% vs. 10.9%, p<0.001). A latissimus dorsi with implant reconstruction after prior radiation therapy failed less often (15.2%) compared with an implant alone after prior radiation therapy (42.2%; p=0.028). The conclusion was that after prior radiation therapy, the addition of autologous tissue to an implant reconstruction can reduce the chances of complications and failure of the reconstruction (Change et al, 2008).
Based on the considerations above, delayed reconstruction using an implant without the addition of autologous tissue following prior radiation therapy is not the preferred approach, considering the high complication rates reported. In such a situation, a transposition flap may be added, which shows a lower complication rate and an acceptable cosmetic result (Chang et al, 2008).
Authorization date and validity
Last review : 01-03-2015
Last authorization : 01-03-2015
The Board of the Dutch Society for Plastic and Reconstructive Surgery (NVPC) will assess whether this guideline is still up-to-date in 2018 at the latest. If necessary, a new working group will be appointed to revise the guideline. The guideline’s validity may lapse earlier if new developments demand revision at an earlier date.
As the holder of this guideline, the NVPC is chiefly responsible for keeping the guideline up to date. Other scientific organizations participating in the guideline or users of the guideline share the responsibility to inform the chiefly responsible party about relevant developments within their fields.
Initiative and authorization
Guideline development was funded by the Quality Fund for Medical Specialists (SKMS) and The Netherlands Organization for Health Research and Development (ZonMw).
Scope and target group
To develop a multidisciplinary, evidence-based guideline for breast reconstruction in women undergoing breast conserving therapy or mastectomy for breast cancer, or following prophylactic mastectomy.
The guideline focuses on all patients with an indication for breast reconstruction following breast conserving therapy or mastectomy. Additionally, the guideline may be applied to breast reconstruction in patients who have undergone surgical treatment for a benign breast condition. The guideline does not comment on the treatment of breast cancer. We refer the reader to the NABON guideline for the treatment of breast cancer (www.richtlijnendatabase.nl), which this guideline complements.
Unfortunately, circumstances did not permit a medical oncologist representing the NVMO to participate in the working group. Thus, the current version lacks a module on chemotherapy and breast reconstruction. The working group strives to create such a module for this guideline in the near future.
Intended audience for the guideline
The guideline aims to provide practical guidance for plastic surgeons and members of the multidisciplinary breast cancer team (surgical oncologist, medical oncologist, radiation oncologist, radiologist, pathologist, psychologist, breast care nurse specialist). A version for patients has recently been developed (https://www.b-bewust.nl/pif_borstreconstructie).
Members of the guideline panel
A multidisciplinary working group was appointed to develop the guideline in October 2011, consisting of representatives from all relevant specialties involved in the care for patients with breast reconstruction (see above for working group membership). Working group members were mandated by their professional organizations. The working group worked on developing the guideline for 2 years. The working group is responsible for the full text of this guideline.
- Dr. M.A.M. Mureau (President), MD, PhD, plastic surgeon, Erasmus MC Cancer Institute, Erasmus University Medical Center Rotterdam
- Professor Dr. R.R.W.J. van der Hulst, MD, PhD, plastic surgeon, Maastricht University Medical Center/Orbis Medical Center/Viecuri Medical Center, Maastricht
- Dr. L. A.E. Woerdeman, MD, PhD, plastic surgeon, Antoni van Leeuwenhoek / Netherlands Cancer Institute, Amsterdam
- Drs. A.A.W.M van Turnhout, MD, plastic surgeon, Tergooi Hospital, Hilversum Site
- N.A.S. Posch, MD, plastic surgeon, Haga Hospital, The Hague
- Dr. M.B.E. Menke-Pluijmers, MD, PhD, oncologic surgeon, Albert Schweitzer Hospital, Dordrecht
- Dr. E.J.T. Luiten, MD, PhD, oncologic surgeon, Amphia Hospital, Breda
- Drs. A.H. Westenberg, MD, radiotherapist/oncologist, Arnhem Radiotherapy Institute, Arnhem
- Dr. J.P. Gopie, PhD, psychologist, Leiden University Medical Center, Leiden
- Dr. H.M. Zonderland, MD, PhD, radiologist, Academic Medical Center, Amsterdam
- Drs. M. Westerhof, MSc, Netherlands Breast Cancer Association, Utrecht
- E.M.M. Krol-Warmerdam MA, V&VN Nurse Specialists, Leiden University Medical Center, Leiden
With support from
- Drs. B.S. Niël-Weise, MD, microbiologist / epidemiologist, senior advisor, Knowledge Institute for Medical Specialists
Declaration of interest
Working group members declared any (financial) ties with commercial companies, organizations or institutions involved in the field covered by the guideline for the past five years in writing. An overview is available on request from the office of the Knowledge Institute for Medical Specialists (KIMS).
Patients are represented by a delegate from the Netherlands Breast Cancer Association in this guideline.
Method of development
Guideline implementation and practical applicability of the recommendations was taken into consideration during various stages of guideline development. Factors that may promote or hinder implementation of the guideline in daily practice were given specific attention.
The guideline is distributed digitally among all relevant professional groups. The guideline can also be downloaded from the Dutch Society for Plastic and Reconstructive Surgery website: www.nvpc.nl, the guideline website: www.richtlijnendatabase.nl and the Quality Organization for Medical Specialists.
Methods and proces
The guideline has been drafted in accordance with the requirements outlined in the ‘Guidelines 2.0’ report of the Guideline Advisory Committee of the Council on Science, Education and Quality (WOK). This report is based on the AGREE II instrument (Appraisal of Guidelines for Research & Evaluation II) (www.agreecollaboration.org), an instrument designed to assess the quality of guidelines with broad international support.
Primary questions and outcome measures
Based on the outcomes of the bottleneck analysis, the president and advisor formulated draft primary questions. These were discussed and defined together with the working group. Subsequently, the working group determined which outcome measures were relevant for the patient for each primary question, examining both desired and undesirable effects. The working group valuated these outcomes based on their relative importance as crucial, important and unimportant.
Literature search and selection strategy
Specific search terms were used to identify published scientific studies related to each individual primary question in Medline, Cochrane and, where necessary, Embase. Additionally, the references of the selected articles were screened for additional relevant studies. Studies offering the highest level of evidence were sought out first. Working group members selected articles identified by the search based on predetermined criteria. The selected articles were used to answer the primary question. The searched databases, the search string or terms used during the search and selection criteria applied are listed in the chapter for each individual primary question.
Quality assessment of individual studies
Individual studies were assessed systematically based on predefined methodological quality criteria in order to assess the risk of biased study results. These assessments may be found in the column ‘Study quality assessment’ in an evidence table.
The relevant study results from all selected articles were presented clearly in evidence tables. The key findings from the literature are described in the literature summary. If studies were sufficiently similar in design, data were also summarized quantitatively (meta-analysis) using Review Manager 5.
Assessment of the level of scientific evidence
A) With regard to intervention questions:
The level of scientific evidence was determined using the GRADE method. GRADE is short for ‘Grading Recommendations Assessment, Development and Evaluation’ (see http://www.gradeworkinggroup.org/) (Atkins et al, 2004).
B) With regard to questions about the value of diagnostic tests, harm or adverse effects, etiology and prognosis:
GRADE cannot be used (yet) for these types of questions. The level of evidence of the conclusion was determined based on the accepted EBRO method (van Everdingen et al, 2004).
Formulation of conclusions
With regard to questions about the value of diagnostic tests, harm or adverse effects, etiology and prognosis, the scientific evidence is summarized in one or more conclusions, listing the level of evidence for the most relevant data.
For interventions, the conclusion does not refer to one or more articles, but is drawn based on the body of evidence. The working group looked at the net benefits of each intervention. This was done by determining the balance between favorable and unfavorable effects for the patient.
When making recommendations, scientific evidence was considered together with other key aspects, such as working group member expertise, patient preferences, costs, availability of facilities and/or organizational aspects. Insofar as they are not part of the systematic literature review, these aspects are listed under ‘Considerations’.
Formulation of recommendations
Recommendations provide an answer to the primary question, and are based on the best scientific evidence available and the most important considerations. The level of scientific evidence and the importance given to considerations by the working group jointly determine the strength of the recommendation. In accordance with the GRADE method, a low level of evidence for conclusions in the systematic literature review does not rule out a strong recommendation, while a high level of evidence may be accompanied by weak recommendations. The strength of the recommendation is always determined by weighing all relevant arguments.
Development of indicators
Along with developing a draft guideline, internal quality indicators were developed to allow monitoring of the implementation of the guideline in daily practice. More information about the method for indicator development may be requested from KIMS.
During the development of this guideline, systematic searches were conducted for research contributing to answering the primary questions. For each primary question, the working group determined whether (additional) scientific research is desirable.
Commentary and authorization phase
The draft guideline was submitted to the (scientific) organizations involved for comment. The guideline was also submitted to the following organizations for comment: Netherlands Breast Cancer Association (BVN), Netherlands Society for Medical Oncology (NVMO), Dutch College of General Practitioners (NHG), Healthcare Insurers Netherlands (ZN), The Dutch Healthcare Authority (NZA), Health Care Insurance Board (CvZ), the Health Care Inspectorate (IGZ), Achmea, CZ, Menzis and VGZ. Comments were collected and discussed with the working group. The draft guideline was updated and finalized by the working group based on the comments. The final guideline was submitted for authorization to the (scientific) organizations involved and authorized by them.
Legal standing of guidelines
Guidelines are not legal prescriptions, but contain evidence-based insights and recommendations that care providers must meet in order to provide high quality care. As these recommendations are primarily based on ‘general evidence for optimal care for the average patient’, care providers may deviate from the guideline based on their professional autonomy when they deem it necessary for individual cases. Deviating from the guideline may even be necessary in some situations. If care providers choose to deviate from the guideline, this should be done in consultation with the patient, where relevant. Deviation from the guideline must always be justified and documented.