Oral Presentation Joint 2016 COSA and ANZBCTG Annual Scientific Meeting

When to do what:  optimizing decisions and outcomes from breast surgery (#91)

Laura Esserman 1
  1. UCLA, CA, United States

One of the best ways to improve the outcomes of women who present with large tumors, and where mastectomy  and radiation and systemic chemotherapy would be needed, is to start with systemic therapy and avoid surgical resection first. Most women will have a response to therapy that is sufficient to avoid mastectomy. This is the ideal outcome if radiation is required. The local recurrence outcomes are not increased in this situation as the key risk for women with more aggressive disease at presentation is distant not local recurrence. Over half of these women may not need to have a mastectomy. Techniques such as breast reduction in a woman with sufficiently large volume of breast tissue can also eliminate the need to mastectomy and is associated with improved satisfaction relative to mastectomy and fewer complications. 

For women who undergo mastectomy, the optimal cosmetic outcome is achieved with total skin sparing techniques and immediate reconstruction. Outcomes have improved over time. The ability to save the entire skin envelope is feasible and oncologically safe.The addition of fat grafting has led to significant improvement in cosmesis. Reduction in complications has resulted from staged reconstructions and use of prepectoral implants for women with larger and smaller skin envelopes, respectively . There is significant controversy over the use of antibiotics and ongoing studies may provide the definitive answer as to whether prolonged use of prophylactic antibiotics in the post operative setting increases the chance of complications by predisposing to resistant organisms or actually prevents infections that lead to implant loss. Use of incisional wound vacs are being tested for their ability to prevent complications in situations where risk of wound breakdown is increased.

For women who undergo either reduction mammoplasty or mastectomy, surgeons should be aware that postmastectomy pain, is not an infrequent complication. It is likely caused by the cauterization of the vessel that accompanies that egress of the T4 and T5 intercostal nerve branches from the chest wall into the breast at the lateral ( 3/9 o’clock) and inferior (6 o’clock) positions