Breast Reconstruction during COVID-19

POSITION STATEMENT REGARDING BREAST RECONSTRUCTION DURING THE COVID-19 PANDEMIC

The Australian Society of Plastic Surgeons (ASPS) and BreastSurgANZ are closely following the development of the COVID-19 pandemic and are here to support members during these challenging times. We have collected resources from around the globe to provide guidance. We will continue to monitor the situation and will update information as it becomes available or changes.

Patients with breast cancer, particularly those undergoing immunosuppressive therapy (chemotherapy) may be at increased risk of contracting coronavirus (COVID-19) and at increased risk of a more severe infection. Consideration should be given to minimising extent of surgery, stay in hospital and risk of complications during the pandemic. This is to reduce the risk of exposure of the patient to COVID-19 and to preserve resources. This may affect decision making regarding breast reconstruction.

Breast Cancer treatment is deemed as category 1 and thus should proceed as clinically indicated. Each patient should continue to be treated as an individual and have their oncologic and possible reconstructive options discussed on a personalised basis. Reconstruction should still be discussed wherever possible. Telehealth should be considered for reconstructive consultations.

DELAYED RECONSTRUCTION AND REVISION SURGERY

Delayed breast reconstruction and planned secondary or revision breast reconstruction are not classified as urgent and thus should be postponed until which time the government and system in your area can accommodate non-urgent elective surgery as deemed safe for patients and staff.

IMMEDIATE RECONSTRUCTION

Wide local excision and total mastectomies should be performed as clinically indicated. Risk reducing mastectomies (e.g. for high genetic risk) should be deferred until after the pandemic. Autologous reconstructive procedures utilize additional resources, prolong surgery and increase the risk of complications and longer inpatient stays. Non-autologous procedures may necessitate an increased number of post-operative face to face visits (such as for tissue expander fill, for seromas or other complications), which also consume additional resources (such as personal protective equipment) and further increase risk of exposure.

RECOMMENDATIONS

• Surgeons should include as part of their informed consent process the issue of performing reconstructive surgery in light of the COVID-19 pandemic and the potential consequences to the patient and others
• In general, reconstructive surgeons should err on the side of caution and delay reconstruction
• Immediate autologous flap reconstruction for breast reconstruction should be delayed where possible (this does not include chest wall wound coverage)
• Immediate tissue expander or direct to implant reconstruction can be evaluated on a case-by-case basis, or where the preservation of the skin envelope will allow for potential autologous reconstruction at a later date. This decision should take into account the likelihood of complications, the age and comorbidities of the patient, the resources utilized, as well as local-regional and individual institutional factors such as the availability of healthcare resources and anticipated availability of resources in the post-operative period
• If oncoplastic reconstruction is a consideration, it should also be evaluated on a case by case basis, depending on the complexity of the reconstruction, the likelihood of complications and other factors as listed above
• Address only the cancer side and avoid prolonged surgery by deferring concurrent contralateral balancing procedures
• If there is uncertainty whether or not a case should proceed during this period, a second opinion is recommended and the rationale to proceed clearly documented

A/Prof Gazi Hussain A/Prof Sanjay Warrier
ASPS President President BreastSurgANZ