Breast Reconstruction

Anatomy and Physiology

The extent of the ablative surgery will dictate the choices available for reconstruction to some extent.[5] The loss of breast skin, with or without loss of the nipple, can be accounted for with either autologous tissue reconstruction or tissue expansion. The loss of underlying muscle (pectoralis major, pectoralis minor, or both) poses challenges for implant-based reconstruction as implants are most reliably placed in a sub-muscular pocket.[6]

The contralateral breast and the abdomen must be examined before determining the reconstructive approach.

The volume, fall, and projection of the contralateral breast are of utmost importance when planning reconstruction, as recreating a symmetric breast is the overall goal. Breast reconstruction can be combined with contralateral mammoplasty to balance the symmetry between the reconstructed and native breasts.

If autologous tissue reconstruction is planned, a careful abdominal examination is required. Prior open abdominal surgery may have resulted in incisions that disrupt the blood supply to one or more potential reconstructive flaps. In addition, the abdomen must be assessed for any incisional, umbilical, or ventral hernias. These are all relative contraindications to abdominal-based flap reconstruction. The degree of subcutaneous adiposity should be noted, as a moderate degree is desirable for many reconstructive flaps. If insufficient subcutaneous adiposity exists, adequate volume may not be achievable in the reconstruction. Contrarily, the survival rate of flaps constructed from a morbidly obese abdomen is diminished. In both instances, non-abdominally based reconstructive flaps, such as latissimus dorsi flaps, or implant-based reconstruction may be offered.

Indications

A significant consideration during the planning process is the timing of reconstructive procedures. Both immediate repair and delayed repair are options. The decision must be tailored to each patient and their specific oncologic situation to ensure optimum safety, oncologic soundness, and final functional and aesthetic outcome.

Immediate repair refers to a reconstruction performed during the same surgical session as the cancer resection. While this prolongs the time under anesthesia, the advantage of using a more natural skin envelope for reconstructive options is considerable. The skin envelope created during skin/nipple-sparing mastectomy can leave the patient with a more natural-appearing breast postoperatively. Oncologic considerations such as stage and BRCA mutation status are key in determining if this approach is reasonable. Immediate reconstruction is affected by the need for adjuvant therapy, specifically radiation therapy. The risk of wound breakdown and other complications is significantly increased when a foreign body, such as a breast implant, is within the radiated field.[7] Patients requiring adjuvant radiation are often best served with autologous tissue reconstruction, whether pedicled or free flap in nature.[8]

Delayed reconstruction is when a patient has a planned mastectomy, then returns to the operating room a second time to perform the reconstructive portion of the procedure. This option is available for patients who may not have decided whether to have breast reconstruction or require adjuvant radiation therapy to optimize outcomes.

Breast restoration utilizing alloplastic implants is discussed in a subsequent article and remains an option for many patients in immediate and delayed scenarios.[9][10]

Contraindications

Contraindications to breast reconstruction include but are not limited to the following historical or clinical conditions:

• Severe lung or cardiac disease
• Collagen vascular disease
• Obesity
• Age greater than 65 years
• Current tobacco use with an unwillingness or inability to stop
• Prior abdominal or thoracic surgery that has interrupted blood supply to potential flaps
• Prior radiation therapy
• Advanced breast cancer

Equipment

A standard breast surgery tray, microvascular tray, and operating microscope are required. In addition, lighted breast retractors such as the Ferriera, Tebbetts, or other such retractors are very helpful.

Personnel

An experienced first assistant or co-surgeon is desirable in any microsurgical case, increasing operative speed and facilitating the overall reconstruction. Similarly, an intraoperative team of nurses and surgical technologists familiar with breast surgery and microsurgery is very desirable.

Technique or Treatment

Tissue Expanders and Implants

Expanders and implants are common breast restoration options because of the simple nature of the procedure. Their use adds minimal time to the oncologic procedure and has a shorter recovery period. As there is no flap donor site, there are no complications from donor-site surgery. However, there can be significant pain associated with tissue expanders, and close follow-up is needed as the expanders are typically inflated weekly. This particular option is a good choice for patients who will not need radiation therapy. Using tissue expanders is also a good alternative for patients undergoing a unilateral mastectomy with little to no ptosis of the remaining breast and decreased subcutaneous adiposity, as implants reduce the natural fall of the breast.

Significant disadvantages of this option include implant infection, capsular contracture, and frequent tissue expansion visits. In addition, the radiated breast is a relative contraindication to tissue expansion, as radiation causes capsular contractures and infections, and it increases the risk of skin necrosis.

Several implant types 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, and the specifics of this choice are beyond the scope of this article. 

This procedure can be performed as an immediate adjunct after the initial mastectomy, using the skin flap left by the breast surgeon. If this approach is chosen for delayed reconstruction, most surgeons will access the flap through the initial scar. This procedure can also be performed via previous scars, an inframammary incision, or circumareolar incisions.

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 or to reinforce the soft tissue, particularly to reinforce the inferior aspect of the breast. After creating the pocket, a tissue expander is inserted, and the muscle is reapproximated. The expanders have a port implanted to be easily accessible through the skin to perform subsequent expansion in the clinic. After the skin envelope is expanded appropriately, which will take several weeks, the patient returns to the operating room later to exchange the expander for the final implant. Issues such as capsular contracture and contralateral asymmetry can be addressed during the exchange procedure.[11]

TRAM Flaps

The transverse rectus abdominis musculocutaneous (TRAM) flap is an excellent option for healthy candidates with the anatomy required for the procedure; the TRAM flap is a workhorse for breast reconstruction. The required anatomy includes a sufficient but not excessive amount of abdominal fat and otherwise fair core musculature. This flap isolates an island of skin, fat, and a portion of the rectus muscle and transposes it to the mastectomy site. Ideal candidates for this surgery are patients without significant comorbidities, such as uncontrolled hypertension or diabetes, as these may compromise the blood supply to the flap. Cigarette smoking is a relative contraindication to the procedure as it compromises the microcirculation of the flap and impairs overall wound healing; many plastic surgeons will require patients to refrain from any nicotine-containing products for at least two weeks before surgery if they cannot entirely quit.

This surgical option has the bonus of creating a natural fall appearance to the new breast mound and simultaneously performing a lipectomy of the abdomen. The drawbacks of this procedure are similar to those in most flaps, with vascular compromise resulting in partial or complete flap failure being the most severe. Since this is a musculocutaneous flap, the patient will have a defect in the anterior abdominal wall that increases the risk of future hernia formation. Similar postoperative care and positioning are adopted as with an abdominoplasty.[12]

The blood supply to the flap classifies TRAM flaps. The most conventional TRAM flap is the pedicled TRAM which uses a pedicled arterial supply from the deep superior epigastric artery and rotates the flap island superiorly to create the new breast mound. This is the most straightforward TRAM flap, as the artery is not dissected, and the flap is merely rotated into its new position.

The muscle-sparing free TRAM flap was developed to minimize the amount of muscle taken from the abdomen. This option dissects the deep inferior epigastric artery perforator and a small muscle area, leaving most of the rectus behind in situ in the abdomen. The deep inferior epigastric perforator (DIEP) and superior epigastric inferior perforator (SIEP) TRAM flap variants are perforator flaps based on the deep inferior epigastric perforator and superficial inferior epigastric vessels, respectively, and have gained prominence in autologous breast reconstruction. The benefits of these procedures are that they take little muscle from the anterior abdominal wall and do not violate the rectus fascia. However, using these flaps requires specialized training to anastomose these fine vessels, typically performed under a microscope, and adds to the operative time. Despite this, these procedures are performed safely and routinely at most breast reconstruction centers.

Latissimus Dorsi Flap

The latissimus dorsi is a broad muscle that extends across a significant portion of the back, creating a flap with many clinical uses. This approach may be an option for patients who wish to have autologous tissue but have too little or too much subcutaneous adiposity or have a history of failed abdominal flap procedures.[13] However, implants or fat grafting may be required 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, though it can be used as a free flap.[14] In the modern era of breast reconstruction, with the widespread utility of the DIEP flap, the latissimus dorsi flap is typically relegated to a secondary option.[14]

Nipple-Areolar Complex Reconstruction

Although unnecessary, creating the nipple-areolar complex (NAC) completes breast reconstruction. This step is psychologically important for patients with breast cancer. Many techniques are used to create a NAC; the basis of all methods is to create a symmetric projection and appearance to its counterpart, whether a unilateral or bilateral mastectomy is performed. If the NAC cannot be spared and subsequently incorporated into the final reconstruction, medical tattooing is a common and highly effective technique to recreate the previous pigmentation of the areola and nipple.[15]

Complications

Immediate

• Bleeding
• Edema
• Tissue necrosis 
• Moderate-to-severe pain
• Breast asymmetry

Long-term

• Sensory changes or loss
• Fat necrosis
• Asymmetry or unevenness
• Undesirable scar
• Hernia formation at the donor site of the muscle flap
• Cancer recurrence

Clinical Significance

For patients, breast reconstruction surgery can help improve confidence in appearance, restore self-confidence, and promote comfort in wearing clothing, including swimsuits and bras. Reconstructive surgery also eliminates the need for uncomfortable prosthetics.

Enhancing Healthcare Team Outcomes

Plastic surgeons primarily perform breast reconstruction. However, in many cases, the primary care provider provides follow-up care. These healthcare professionals need to know the different types of breast construction procedures and how to provide follow-up care for breast cancer screening. Breast reconstruction is only performed after the patient has completed the treatment course for breast cancer and is deemed free of malignancy. Finally, before breast reconstruction, primary care providers should encourage the patient to discontinue smoking to reduce postoperative complications. The overall outcomes after breast reconstruction are good.[16]