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ASPS Clinical Practice Guideline Summary on Breast Reconstruction with Expanders and Implants

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ASPS Clinical Practice Guideline Summary on Breast Reconstruction with Expanders and Implants CME ASPS Clinical Practice Guideline Summary on Breast Reconstruction with Expanders and Implants Amy Alderman, M.D., M.P.H. Learning Objectives: After reading this article, participants should be able to: Karol Gutowski, M.D. 1. Understand the evidence regarding the timing of expander/implant breast re- Amy Ahuja, M.P.H. construction in the setting of radiation therapy. 2. Discuss the implications of a Diedra Gray, M.P.H. patient’s risk factors for possible outcomes and complications of expander/implant Postmastectomy breast reconstruction. 3. Implement proper prophylactic antibiotic protocols. 4. Use Expander/Implant Breast the guidelines to improve their own clinical outcomes and reduce complications. Reconstruction Guideline Summary: In March of 2013, the Executive Committee of the American Society Work Group of Plastic Surgeons approved an evidence-based guideline on breast reconstruc- Arlington Heights, Ill. tion with expanders and implants, as developed by a guideline-specific work group commissioned by the society’s Health Policy Committee. The guideline addresses ten clinical questions: patient education, immediate versus delayed reconstruction, risk factors, radiation therapy, chemotherapy, hormonal therapy, antibiotic prophylaxis, acellular dermal matrix, monitoring for cancer recur- rence, and oncologic outcomes associated with implant-based reconstruction. The evidence indicates that patients undergoing mastectomy should be offered a preoperative referral to a plastic surgeon. Evidence varies regarding the as- sociation between postoperative complications and timing of postmastectomy expander/implant breast reconstruction. Evidence is limited regarding the opti- mal timing of expand/implant reconstruction in the setting of radiation therapy but suggests that irradiation to the expander or implant is associated with an increased risk of postoperative complications. Evidence also varies regarding the association between acellular dermal matrix and surgical complications in the setting of postmastectomy expander/implant reconstruction. Data support the use of an appropriate preoperative antibiotic, but antibiotics should be dis- continued within 24 hours of the procedure, unless a surgical drain is present. Furthermore, postmastectomy expander/implant breast reconstruction does not adversely affect oncologic outcomes. (Plast. Reconstr. Surg. 134: 648e, 2014.) he American Cancer Society estimates that decision-making process can be overwhelming for nearly 230,000 American women are diag- patients. The American Society of Plastic Surgeons nosed annually with invasive breast can- (ASPS) is committed to providing decision sup- T1 cer. Many women will undergo a mastectomy port, access to reconstruction, and quality care for and therefore have the option of breast recon- all patients. Fortunately, through advocacy efforts, struction. The cancer diagnosis and treatment the ASPS has reported a 3 percent increase in the use of breast reconstruction in just 1 year, with From the American Society of Plastic Surgeons. nearly 100,000 procedures performed in 2011, Received for publication October 4, 2013; accepted Novem- and the majority of these procedures involve a ber 8, 2013. tissue expander and implant.2 The increased use A complete list of the guideline authors is as follows: Amy Al- derman, M.D., M.P.H.; Loree Kalliainen, M.D.; Amy Ahuja, M.P.H.; Bob Basu, M.D.; Phillip Blondeel, M.D.; Hiram Cody Disclosure: Dr. Basu has a research support re- III, M.D.; Diana Frame, M.P.H.; Nolan Karp, M.D.; Carol cipient and consultant relationship with LifeCell Lee, M.D.; Valerie Lemaine, M.D., M.P.H.; Raman Mahabir, Corp.; Dr. Karp has a research support recipient re- M.D.; Galen Perdikis, M.D.; Neal Reisman, M.D., J.D.; Karie lationship with Allergan, Inc.; Dr. Lemaine has a Rosolowski, M.P.H.; Kathryn Ruddy, M.D., M.P.H.; Mark grant recipient relationship with Allergan, Inc.; Dr. Schusterman, M.D.; DeLaine Schmitz, R.N., M.S.H.L.; Jaime Schwartz has a consultant relationship with Mentor Schwartz, M.D.; and Jennifer Swanson, B.S., M.Ed. Worldwide, LLC, and Covidien. None of the other Copyright © 2014 by the American Society of Plastic Surgeons authors has any relevant disclosures. DOI: 10.1097/PRS.0000000000000541 648e www.PRSJournal.com 6OLUME .UMBERs"REAST2ECONSTRUCTION'UIDELINE of postmastectomy breast reconstruction over the GUIDELINE DEVELOPMENT PROCESS course of just 1 year highlights the significance of The ASPS evidence-based clinical practice maintaining patient safety and optimizing surgical guidelines are developed using an objective, outcomes. transparent approach, to minimize bias. A pro- Breast reconstruction is a common consider- spective systematic review of the current litera- ation for breast cancer patients undergoing mas- ture on breast reconstruction with expanders and tectomy. Breast reconstruction can be performed implants was completed. A complete summary of in an immediate or delayed setting using a vari- the methods used to conduct the systematic review ety of techniques, including an implant-based and complete the critical appraisal process for the approach or an autologous tissue technique. A guideline can be found at: http://www.plastic- significant number of implant-based breast recon- surgery.org/Documents/medical-professionals/ struction procedures are two-stage processes, health-policy/evidence-practice/breast-recon- involving the insertion of a tissue expander. Once struction-expanders-with-implants-guidelines.pdf. the expansion process is complete, the final Committee Composition implant can be placed, using either a saline- or silicone gel–filled device. The guideline work group was chaired by Amy Alderman, M.D., M.P.H., as selected by the ASPS Health Policy Committee. The Health Policy Com- DISCLAIMER mittee also selected additional work group mem- Evidence-based guidelines are strategies for bers after a thorough review of applicants. The patient management, developed to assist physi- work group composition was a diverse represen- cians in clinical decision making. This guideline tation of U.S. regions; practice type; and clinical, was developed through a comprehensive review of research, and evidence-based medicine experi- the scientific literature and consideration of rel- ence and expertise. Three stakeholder organiza- evant clinical experience, and describes a range tions, including the American Society of Breast of generally acceptable approaches to diagnosis, Surgeons, the American College of Radiology, and management, or prevention of specific diseases the American Society of Clinical Oncology, were or conditions. This guideline attempts to define also invited to participate in the guideline devel- opment process, which was facilitated by ASPS principles of practice that should generally meet staff. All workgroup members declared potential the needs of most patients in most circumstances. conflicts of interest, and these were present in a However, this guideline should not be con- minority of workgroup members, consistent with strued as a rule, nor should it be deemed inclusive the Institute of Medicine’s recommendations for of all proper methods of care or exclusive of other guideline development.3 methods of care reasonably directed at obtaining the appropriate results. It is anticipated that it will be necessary to approach some patients’ needs in LITERATURE SEARCH different ways. The ultimate judgment regarding A comprehensive search of PubMed, the the care of a particular patient must be made by Cumulative Index to Nursing and Allied Health the physician in light of all the circumstances pre- Literature, and the Cochrane Library was per- sented by the patient, the available diagnostic and formed by a guideline development methodolo- gist using various combinations of the following treatment options, and available resources. search terms: “mammaplasty AND reconstruction” This guideline is not intended to define or OR “breast reconstruction,” and a wide range of serve as the standard of medical care. Standards MeSH indexing terms. The initial search identi- of medical care are determined on the basis of fied a total of 2749 articles that were subject to all the facts or circumstances involved in an indi- Level I screening, which were then narrowed to 62 vidual case and are subject to change as scientific studies, deemed relevant and of high to moderate knowledge and technology advance and as prac- quality (Table 1). These studies were evaluated by tice patterns evolve. This guideline reflects the means of the ASPS critical appraisal process and state of current knowledge at the time of publi- were used to develop practice recommendations. cation. Given the inevitable changes in the state Recommendations were developed through a of scientific information and technology, this consensus process. After a thorough review of the guideline will be reviewed, updated, and revised evidence, Guideline Work Group members jointly periodically. drafted statements for each recommendation 649e 0LASTICAND2ECONSTRUCTIVE3URGERYs/CTOBER Table 1. ASPS Scale for Grading Recommendations Grade Descriptor Qualifying Evidence Implications for Practice A Strong recommendation Level I evidence or consistent Clinicians should follow a strong recommendation findings from multiple unless a clear and compelling rationale for an studies of levels II, III, or IV alternative approach is present. B Recommendation Levels II, III, or IV evidence Generally, clinicians should follow a recommendation and findings are generally but should
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