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Breast Reconstruction

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 Breast cancer is the second most common malignant tumor, affecting 1 in 8 women throughout their lifetimes, and second most common cause of cancer death for women in the US. However, due to modern advances in detection and treatment options, the number of breast cancer survivors, as of 2008, is approximately 2.5 million. With better survival rates, the focus of breast cancer treatment has grown to include not only surgery, chemotherapy, and radiation, but also the option for post-mastectomy breast reconstruction. Aesthetic outcomes after breast surgery and patient quality of life have become a priority in line with treating the cancer itself. Studies demonstrate that breast reconstruction has a positive psychological benefit on women, restoring the sense of femininity.  Breast reconstruction can help alleviate feelings of deformity that often follow mastectomy and eliminate the constant reminder of disease. However, only 10% of post-mastectomy women will undergo breast reconstruction, often not because of preference, but due to lack of education and awareness regarding reconstructive procedures. Hopefully, this article will give women a better understanding of the basic concepts behind breast reconstruction, so that they can make an informed decision regarding their comprehensive breast cancer care.




 The timing of breast reconstruction is an important consideration. Immediate reconstruction is done at the same time as the mastectomy (usually with a skin sparing mastectomy) and offers the potential for excellent cosmetic outcomes, reduced psychological burden, and decreased overall costs.   However, immediate reconstruction may not be best suited for every individual and the decision to proceed with immediate or delayed reconstruction should be discussed with the reconstructive plastic surgeon, particularly if postoperative radiation therapy is required, or a patient has significant oncologic or medical concerns. In general, radiation therapy has adverse effects on the aesthetic outcomes of certain types of breast reconstruction and a delayed reconstruction may be advised if certain methods of reconstruction are to be pursued. Delayed reconstruction is usually done 3-6 months after mastectomy or, if radiation is needed, 6 months or more after radiation.



Types of Breast Reconstruction


 The type of breast reconstruction is an important point to consider. First, one must determine whether the reconstructive procedure is to follow a total mastectomy or a partial mastectomy (lumpectomy). Women with small breasts are especially susceptible to breast deformity after partial mastectomy and may be better suited to a total mastectomy with breast reconstruction. Large-breasted women who have had a partial mastectomy may benefit from partial breast reconstruction techniques utilizing reduction mammoplasty techniques. In such a procedure, the remaining parenchymal tissue is rearranged on the affected side and the focus is to achieve symmetry by reducing the size of the contralateral breast. The main concern in partial breast reconstruction is to ensure that the margins of the lumpectomy are negative for cancer. Otherwise the reconstruction may be compromised if further surgery is needed to address the residual cancer. 


 For a total mastectomy, breast reconstruction can be undertaken with a number of different approaches. Tissue expander and implants are usually the first option to consider. These are silicone shell expanders placed underneath the pectoralis major muscle that are later exchanged for permanent implants. However, unlike implants placed for cosmetic reasons, the initial expanders are not inflated to the total volume immediately at the time of the mastectomy.  Rather, they are inflated sequentially on a weekly basis for 6-8 weeks. It is this slow serial inflation that allows the muscle and overlying mastectomy skin to stretch and expand into a pocket large enough to accommodate the full-size implant. Typically, three months after the final volume is completed, the expander(s) are replaced with the permanent silicone or saline implants; three months later after the exchange, the nipple is reconstructed and the overall reconstruction is complete. The operation described may be combined with an autologous myocutaneous flap, such as a latissimus dorsi flap, particularly if the patient has already had radiation; in order to bring in well-vascularized and non-radiated tissue that can stretch during expansion to create the breast mound.  In addition, many reconstructive surgeons incorporate a bioprosthetic mesh such as Alloderm® with the expander/implant reconstruction to improve the cosmetic outcome of the procedure, stretch of the lower half of the breast (creating a more natural shape) and reduce the time to achieving final expansion since more volume can usually be placed at the initial operation.


 Autologous (native tissue) flaps are sections of skin, fat and/or muscle, which are removed from another location on the body, usually the abdomen or back, and relocated to the mastectomy site.   Fundamentally, the mastectomy site gains tissue, to make a new breast, and the “donor site” loses tissue.  The loss can be favorable when tissue is taken from the abdomen, giving the patient the added benefit of  a “tummy tuck”.  Exactly how the tissue is relocated, pedicled or free, is determined by the reconstructive surgeon and the patient’s individual anatomy. A pedicled flap is mobilized but not completely disconnected from its donor site. It is swung around to the mastectomy site. This allows for the relocated tissue to keep its original blood supply even despite being moved to a different location on the body. The most common pedicled flaps used for breast reconstruction are the transverse rectus abdominis myocutaneous (TRAM) flap from the abdomen and the Latissimus dorsi (LD) flap from the back. Pedicled TRAM flaps preserve circulation from the superior epigastric vessels and LD flaps from the thoracodorsal vessels. LD flaps usually also require tissue expander implants in order to achieve the appropriate volume for a breast reconstruction.


 Free flaps, on the other hand, do not stay connected to the original blood supply. The flap is completely disconnected “free” from its donor site and repositioned to the  mastectomy site. Blood vessels in the flap must be connected, or reanastamosed, with existing vasculature in the mastectomy site, usually the internal mammary or thoracodorsal vessels, in order to maintain the viability of the tissue. Therefore, free flap breast reconstructions are technically more challenging and require the expertise of a microvascular surgeon.  A free breast reconstruction may provide superior outcomes with a better blood supply in certain patients, particularly if a larger breast is required, and offer preservation of abdominal musculature if a perforator type flap is chosen (e.g. MS-TRAM or muscle-sparing TRAM, and DIEP or deep inferior epigastric perforator flap).  For the right candidate, a free flap breast reconstruction is safe and useful method of reconstruction and can provide a excellent cosmetic and functional results. 


Advantages and Disadvantages


 Complications after mastectomy and breast reconstruction can occur just as with any other surgical procedure.   The mastectomy surgery can be associated with necrosis or death of the mastectomy skin flaps (particularly in smokers), asymmetry, contour irregularities, lymphedema if lymph node dissection is required, sensory changes of the mastectomy skin as well as need for further surgery.  


 Similarly, each type of breast reconstruction has its advantages and disadvantages. Implants have no donor site morbidity, shorter operations, and quicker recovery times. However, the time to final results tends to be longer and implant-related complications including infection, malposition, capsular contracture, rupture/leakage, and deflation are possible.  This method of reconstruction is often not used solely in patients who have had previous chest wall radiation therapy. If being used for patients who will require later radiation, timing of the exchange will have to be coordinated with the radiation specialist and oncologist. 


 LD flaps are reliable and can offer good cosmetic results. However, they require more surgery and often are combined with tissue expander/ implants.  Use of the latissimus muscle is associated with potential donor site (scarring, contour irregularities of the back) in additional to implant-related complications. Abdominal-based (TRAM) flaps avoid implant complications, feel more natural, respond naturally to patient weight changes, and have the added cosmetic benefit of abdominoplasty (“tummy tuck”) during the same operation. They too have potential complications, which include partial or complete flap failure, fat necrosis, and hernias due to a weak abdominal wall among others. Finally, free TRAM flaps have the higher demands of microvascular surgery and can be associated with microvascular thrombosis, but certain types may offer reduced abdominal muscle sacrifice. 


 In general, breast reconstruction is safe and has low risk for complications.  A thoughtful discussion with a trained plastic surgeon regarding patient suitability and  breast reconstruction options will uncover the method that can best meet the patient’s goals and expectations and yield excellent aesthetic and functional outcomes.   




George Tun; Anuja Antony MD, MPH; Michael Warso MD





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