Surgical And Oncological Outcomes Of Immediate Prosthetic Breast Reconstruction With Conjoined Fascial Flaps

Purpose:Assess the feasibility as well as the surgical and oncological safety of immediate prosthetic breast reconstruction with the conjoined facia as the coverage following conservative mastectomy.Methods:Part Ⅰ:The indications,anatomical features and surgical procedures of a modified method for harvesting the conjoined fascia surrounding the breast as the coverage of prostheses in integrated conservative mastectomy(nipple-sparing mastectomy,NSM or skin-sparing mastectomy,SSM)and immediate breast reconstruction were introduced.Classic cases were presented.BREAST-Q was used for assessing patient-reported outcomes and a rating scale was used by surgeons to assess the objective outcomes of reconstructions.Part Ⅱ:Patients with breast cancer who receiving conservative mastectomies and immediate prosthetic breast reconstruction between January 2014 and December 2019 were retrospectively reviewed.The rates of post-operative complications and explantation were compared between patients with fascia and those with conventional methods(submuscular or with mesh).Single factor and multi-factor analyses were used to investigate the risk factors of post-operative complications.Part Ⅲ:The rates of local/regional relapse,distant metastasis,and overall survival were compared.Survival analyses were employed to comare the local/regional relapse free survival(LRFS),disease-free survival(DFS)and overall survival(OS).Single factor and multi-factor analyses were used to investigate the risk factors of local/regional relapses.Results:Part Ⅰ:The cojoined facia was composed of pectoral major facia,serratus anterior fascia,external oblique abdominis facia and rectus abdominis facia.Tumescent and sharp dissecting techniques were applied during NSM or SSM and the cojoined facia could be preserved as a whole,which could be used with pectoral major muscle as the coverage of prostheses.This method is simple、consistent and reliable,providing consistent aesthetic outcomes and satisfaction.Part Ⅱ:A total of 770 breast cancer patients with 788 cases of integrative mastectomy and immediate prosthetic reconstruction were reviewed in our center.The facial method was applied in 250 cases while conventional methods were used in the left 538 cases.The facial group had higher rates of using NSM and permanent implant("one stage" method)and also higher rates of receiving neo-adjuvant chemotherapy and adjuvant radiation therapy.The conventional group had higher average initial volume of prostheses when compared with that of the facial group(average volumes were 273.9ml±79.4ml and 246.7ml±58.1ml,respectively,with P<0.01).The facial group had lower rates of major postoperative complications needing surgical intervention and explantation(complication,1.2%vs 6.1%,explantation 1.2%vs 4.3%,respectively,with both P<0.05)).Older age,higher volume of prosthesis and radiation were risk factors of post-operative complication.Part Ⅲ:Patients were the same as Part Ⅱ.After a median follow-up of 33 months(range,11-84 months),the facial group had higher rate of local/regional relapse compare with that of conventional group(4.4%vs 1.75%,P=0.02).After adjusting disease stage and other risk factors with Cox regression,using of facia per se was not an independent risk factor of relapse(P=0.08).The facial group and the conventional group had similar DFS and OS.Younger age,larger post-operative invasive lesion and negative hormonal receptor status were risk factors of local/regional relapse.Conclusion:Conjoined fascia-based prosthetic reconstruction following conservative mastectomy is a feasible and simple,easy-to-learn surgical procedure.The rate of developing post-operative complication was lower in patients with facia-based reconstruction compared with patients with conventional prosthetic reconstruction.Older age,higher volume of prosthesis and radiation were risk factors of post-operative complication.After adjusting factors of disease,facia-based reconstruction has similar rates of local-regional relapse survival,disease-free survival and overall survival.Younger age,larger tumor on pathological examination and negative hormonal receptor status were risk factors of local-regional relapse in patients receiving immediate prosthetic reconstruction.