Breast cancer is the most common cause of cancer and the second leading cause of cancer death in women in the United States. The treatment has progressively improved with new advances in endocrine therapy, early detection, and breast conservation surgical techniques. However, for patients undergoing mastectomy, the additional concern of a deforming surgery after a cancer diagnosis plays a large factor in the patient’s treatment. It is the goal of the plastic surgeon, along with the patient and their breast surgeon, to develop a plan to restore the patient’s body image. Many factors play a role in the reconstruction process, and it is important to discuss all options with the patient to give them the best results. From the timing of the procedure to procedure choice and use of chemoradiation, the entire scope of the cancer treatment must be considered before proceeding with reconstruction.
A significant consideration during the planning process is the timing of the reconstructive procedure. The patient has the option of an immediate repair or delayed repair. The immediate repair is a reconstructive approach during the same cancer surgery. This prolongs the time under anesthesia but has the considerable advantage of using a more natural skin envelope for reconstructive options. The skin envelope after skin/nipple sparing mastectomy can leave the patient with a more natural appearing breast postoperatively. The delayed type of repair occurs when a patient has a planned mastectomy and then returns to the operating room at a later date to perform the reconstruction portion of the procedure. This option is available for patients who may not have a concrete decision about their reconstruction or in patients who need adjuvant radiation therapy.
Contraindications to breast reconstruction include the following:
Tissue Expanders and Implants
Expanders and implants are a common option because of the simple nature of the procedure. It adds little time to the initial, oncologic procedure and has a shorter recovery period. Another benefit of this option is the that no donor site is needed, so there are no complications from donor-site surgery. This particular option is a good choice for patients who are thin and require bilateral mastectomies. It is also a good alternative for thin patients who are undergoing a unilateral mastectomy with little to no ptosis on the remaining breast as implants decrease the natural fall of the breast. Major disadvantages of this option include implant infection, capsular contracture, and frequent visits for tissue expansion. It is also avoided in the irradiated breast as the radiation causes capsular contractures, infection, and risks skin necrosis. Many different implants are available including saline or silicone gel, round or anatomically shaped, and smooth or textured. The risks and benefits of each implant should be thoroughly addressed with the patient.
The procedure is typically performed as an immediate option during the initial surgery using the skin flap left by the breast surgeon. If performed during delayed reconstruction, most surgeons will access the flap through the initial scar. The pectoralis major muscle is incised and lifted from the chest wall. Some plastic surgeons will then augment the muscle by adding an acellular dermal matrix to create a larger pocket. After the pocket is created, using careful technique, a tissue expander is inserted and the muscle is reapproximated over this. These expanders have a port that is easily accessible through the skin in order to perform the expansion in the clinic. After the skin envelope is expanded appropriately, the patient returns to the operating room at a later date to exchange the expander for the final implant. During the exchange procedure, issues such as capsular contracture and contralateral asymmetry can be addressed.
The transverse rectus abdominis musculocutaneous (TRAM) flap is an excellent option for healthy candidates who have the anatomy desired for the procedure. This flap excises an island of skin, fat, and a portion of the rectus muscle and transposes it to mastectomy site. Ideal candidates for this surgery are patients without significant comorbidities such as uncontrolled hypertension or diabetes, as this would compromise the blood supply to the flap. Cigarette smoking would be a contraindication to this choice as it would destroy the vasculature of the flap. The body type is also of particular importance. This procedure is best for patients with an acceptable amount of excessive abdominal subcutaneous tissues which would translate to ideal volumes for breast symmetry. This option has an added bonus of creating a natural fall appearance to the new breast mound and performing a lipectomy of the abdomen at the same time. The drawbacks of this procedure are like those with most flaps, and the vasculature of the flap is of vital importance. If the vasculature is compromised, the flap will fail and result in necrosis. Since this is a musculocutaneous flap, there is a defect in the abdominal wall that is high risk for hernia formation.
TRAM flaps are classified by the blood supply to the flap. The most conventional of all TRAM flaps is the pedicled TRAM which uses a pedicled arterial supply from the deep superior epigastric artery and rotates the flap island to create the new breast mound. This is the simplest of the TRAM flaps as the artery is not dissected and the flap is merely rotated into its new position. The muscle-sparing free TRAM flap was subsequently developed to minimize the amount of muscle taken. This option dissects out the deep inferior epigastric artery perforator and a small area of muscle leaving a majority of the rectus behind. The DIEP and SIEP TRAM flaps are perforator flaps based on the deep inferior epigastric perforator and superficial inferior epigastric vessel respectively. They add the benefit of taking no muscle and not violating the rectus fascia respectively. However, use of these flaps requires specialized training to anastomose these fine vessels typically performed under a microscope.
Latissimus Dorsi Flap
The latissimus dorsi is a broad muscle that extends across a significant portion of the back. This creates a flap with extensive uses. It may be an option for patients who wish to have autologous tissue but are too thin, have previous failed abdominal flaps, or are obese. It may, however, require the use of implants or fat grafting because the shape and thickness of the flap may not provide the necessary volume. This flap is typically supplied in a pedicled fashion from the thoracodorsal artery.
Nipple Areolar Complex Reconstruction
Although not necessary, the nipple-areolar complex (NAC) completes the breast reconstruction process. There are many different techniques used to create a new nipple, but the basis of all techniques is to create projection which is symmetric to its counterpart whether a unilateral or bilateral mastectomy is performed. The use of tattooing is a common and effective technique to recreate the previous pigmentation of the areola.