Clinical practice guidelines for post-mastectomy breast reconstruction: Chinese Society of Breast Surgery (CSBrS) practice guidelines 2021



## Level of evidence and recommendation strength
Level of evidence standard [bib_ref] Clinical practice guidelines for sentinel lymph node biopsy in patients with early-stage..., Ye [/bib_ref] Recommendation strength standard [bib_ref] Clinical practice guidelines for sentinel lymph node biopsy in patients with early-stage..., Ye [/bib_ref] Recommendation strength review committee There were 76 voting committee members for this guideline: 62 breast surgeons (81.6%), four oncologists (5.3%), four radiologists (5.3%), two pathologists (2.6%), two radiation therapists (2.6%), and two epidemiologists (2.6%).

## Target audience
Clinicians specializing in breast diseases in China.

## Recommendations
Recommendation 1: Indications.II A 3.2 Delayed breast reconstructionII A 3.3 Delayed-immediate breast reconstruction [bib_ref] Delayed-immediate breast reconstruction, Kronowitz [/bib_ref] [bib_ref] Delayed versus delayed-immediate autologous breast reconstruction: a blinded evaluation of aesthetic outcomes, Albino [/bib_ref] II A [bib_ref] Breast reconstruction after breastcancer surgery, Beier [/bib_ref] [bib_ref] Breast reconstruction with anatomical implants: a review of indications and techniques based..., Gardani [/bib_ref] [bib_ref] Immediate transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction in underweight Asian..., Kim [/bib_ref] II A 4.2 Deep inferior epigastric perforator (DIEP) flap breast reconstruction [bib_ref] Breast reconstruction after breastcancer surgery, Beier [/bib_ref] [bib_ref] Breast reconstruction with anatomical implants: a review of indications and techniques based..., Gardani [/bib_ref] [bib_ref] Risk of recurrence and death in patients with breast cancer after delayed..., Adam [/bib_ref] II A

## Indications

## Level of evidence

## Latissimus dorsi flap
(LDF) breast reconstruction [bib_ref] Breast reconstruction after breastcancer surgery, Beier [/bib_ref] [bib_ref] Breast reconstruction with anatomical implants: a review of indications and techniques based..., Gardani [/bib_ref] II A Recommendation 5: Prosthetic breast reconstruction.

## Prosthetic breast reconstruction
Level of evidence Recommendation strength 5.1 Immediate implant-based breast reconstruction (one-stage method) [bib_ref] Breast reconstruction with anatomical implants: a review of indications and techniques based..., Gardani [/bib_ref] II A 5.2 Combined tissue expander and prosthetic breast reconstruction (two-stage method) [bib_ref] Breast reconstruction with anatomical implants: a review of indications and techniques based..., Gardani [/bib_ref] II A [bib_ref] Quality of life and patient satisfaction after one-stage implant-based breast reconstruction with..., Negenborn [/bib_ref] [bib_ref] Mesh versus acellular dermal matrix in immediate implant-based breast reconstruction -a prospective..., Gschwantler-Kaulich [/bib_ref] [bib_ref] Surgical studies of reconstructive breast surgery -an overview of the topics at..., Paepke [/bib_ref] II A 7.2 Titanium-coated polypropylene mesh (TCPM) [bib_ref] Mesh versus acellular dermal matrix in immediate implant-based breast reconstruction -a prospective..., Gschwantler-Kaulich [/bib_ref] [bib_ref] Surgical studies of reconstructive breast surgery -an overview of the topics at..., Paepke [/bib_ref] II A

# Discussion
Among malignancies in Chinese women, breast cancer has the highest incidence. [bib_ref] Cancer statistics in China, Chen [/bib_ref] With improvements in breast cancer screening and early diagnosis in China, the quality of life of approximately 30% of patients with early-stage breast cancer can be improved through breast-conserving surgery. However, more than 60% of breast cancer patients still require mastectomy. [bib_ref] Current status and factors influencing surgical options for breast cancer in China:..., Yang [/bib_ref] [bib_ref] Comparison of breastconserving therapy vs mastectomy in women under age 40: national..., Lazow [/bib_ref] The National Comprehensive Cancer Network (NCCN) guidelines suggest that all breast cancer patients who undergo mastectomy should be able to choose to undergo breast reconstruction surgery.Additionally, the NCCN guidelines indicate that inflammatory breast cancer is an absolute contraindication for breast reconstruction [bib_ref] Challenging a traditional paradigm: 12-year experience with autologous free flap breast reconstruction..., Chang [/bib_ref] and that smoking and obesity are relative contraindications. [bib_ref] Obesity and breast reconstruction: complications and patientreported outcomes in a multicenter, prospective..., Srinivasa [/bib_ref] [bib_ref] Smoking as an independent risk factor for postoperative complications in plastic surgical..., Toyoda [/bib_ref] [bib_ref] The association between smoking and plastic surgery outcomes in 40,465 patients: an..., Goltsman [/bib_ref] Regardless of whether prosthetic or autologous breast reconstruction is performed, smoking and obesity increase the risk of various breast reconstruction-related complications. [bib_ref] Obesity and breast reconstruction: complications and patientreported outcomes in a multicenter, prospective..., Srinivasa [/bib_ref] [bib_ref] Smoking as an independent risk factor for postoperative complications in plastic surgical..., Toyoda [/bib_ref] [bib_ref] The association between smoking and plastic surgery outcomes in 40,465 patients: an..., Goltsman [/bib_ref] Locally advanced breast cancer, radiotherapy history, stage IV breast cancer with distant metastasis, and connective tissue disease are not contraindications for breast reconstruction. The expert group believes that breast reconstruction for these patients is not supported by a high level of medical evidence.
Breast reconstruction can be categorized as immediate, delayed, and delayed-immediate according to the timing. Immediate breast reconstruction refers to breast reconstruction performed with mastectomy.Delayed breast reconstruction is generally performed one year after mastectomy or more than six months after radiotherapy.In delayedimmediate breast reconstruction, a tissue expander is implanted during mastectomy to preserve the skin and aesthetic structure of the breast region to the fullest extent. [bib_ref] Delayed-immediate breast reconstruction, Kronowitz [/bib_ref] Autologous breast reconstruction is an important breast reconstruction method. [bib_ref] Breast reconstruction after breastcancer surgery, Beier [/bib_ref] [bib_ref] Breast reconstruction with anatomical implants: a review of indications and techniques based..., Gardani [/bib_ref] Commonly used autologous flaps for breast reconstruction include the transverse rectus abdominis myocutaneous flap, [bib_ref] Breast Transverse Rectus Abdominus Muscle Procedure, Goodenough [/bib_ref] deep inferior epigastric perforator flap, [bib_ref] Risk of recurrence and death in patients with breast cancer after delayed..., Adam [/bib_ref] and latissimus dorsi flap (LDF).
Among all breast reconstruction methods, prosthetic breast reconstruction is the most common surgical procedure after breast cancer surgery. [bib_ref] Breast reconstruction after breastcancer surgery, Beier [/bib_ref] [bib_ref] Breast reconstruction with anatomical implants: a review of indications and techniques based..., Gardani [/bib_ref] Prosthetic breast reconstruction includes one-stage and two-stage reconstruction (with a tissue expander combined with prosthetic breast reconstruction). [bib_ref] Breast reconstruction after breastcancer surgery, Beier [/bib_ref] The expert group agrees that two-stage reconstruction requires two surgeries and may obtain better breast aesthetics through adjustments made during the second surgery.
Combined LDF and prosthetic breast reconstruction is another surgical procedure for breast reconstruction. The use of LDF alone for breast reconstruction may not achieve an ideal aesthetic effect due to insufficient donor-site volume, and a prosthesis will need to be implanted under the LDF to replenish the volume of the reconstructed breast. The expert group believes that combined LDF and prosthetic breast reconstruction can not only compensate for the deficiency of insufficient donor-site tissue in LDF breast reconstruction but also avoid the problem of insufficient surface coverage of the prosthesis.
The strength and thickness of prosthesis coverage during prosthetic breast reconstruction are key factors that determine the appearance of the breast after reconstruction. Patches used for breast reconstruction can be divided into two categories: patches made of bioderived materials, Chinese Medical Journal 2021;134 [bib_ref] Surgical studies of reconstructive breast surgery -an overview of the topics at..., Paepke [/bib_ref] www.cmj.org such as acellular dermal matrix, [bib_ref] Quality of life and patient satisfaction after one-stage implant-based breast reconstruction with..., Negenborn [/bib_ref] [bib_ref] Mesh versus acellular dermal matrix in immediate implant-based breast reconstruction -a prospective..., Gschwantler-Kaulich [/bib_ref] [bib_ref] Surgical studies of reconstructive breast surgery -an overview of the topics at..., Paepke [/bib_ref] and patches made of synthetic materials, such as titanium-coated polypropylene mesh. [bib_ref] Mesh versus acellular dermal matrix in immediate implant-based breast reconstruction -a prospective..., Gschwantler-Kaulich [/bib_ref] [bib_ref] Surgical studies of reconstructive breast surgery -an overview of the topics at..., Paepke [/bib_ref] With advances in breast cancer diagnosis and treatment concepts as well as socioeconomic and cultural development in China, the aesthetic requirements of breast cancer patients are gradually increasing, as is the percentage of patients undergoing breast reconstruction. [bib_ref] Current status and factors influencing surgical options for breast cancer in China:..., Yang [/bib_ref] Conflicts of interest
None.