Breast reconstruction

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Breast reconstruction
Breast reconstruction 2.jpg
Result of breast reconstruction after mastectomy. Nipple missing, and cicatrix (scar) is prominent.
Specialty plastic surgeon

Breast reconstruction is the surgical process of rebuilding the shape and look of a breast, most commonly in women who have had surgery to treat breast cancer. It involves using autologous tissue, prosthetic implants, or a combination of both with the goal of reconstructing a natural-looking breast. This process often also includes the rebuilding of the nipple and areola, known as nipple-areola complex (NAC) reconstruction, as one of the final stages.

Contents

Generally, the aesthetic appearance is acceptable to the woman, but the reconstructed area is commonly completely numb afterwards, which results in loss of sexual function as well as the ability to perceive pain caused by burns and other injuries. [1]

Timing

Breast reconstruction can be performed either immediately following the mastectomy or as a separate procedure at a later date, known as immediate reconstruction and delayed reconstruction, respectively. The decision of when breast reconstruction will take place is patient-specific and based on many different factors. Breast reconstruction is a large undertaking that usually requires multiple operations. These subsequent surgeries may be spread out over weeks or months.

Immediate reconstruction

Breast reconstruction is termed "immediate" when it takes place during the same procedure as the mastectomy. Within the United States, approximately 35% of women who have undergone a total mastectomy for breast cancer will choose to pursue immediate breast reconstruction. [2] One of the inherent advantages of immediate reconstruction is the potential for a single-stage procedure. This also means that the cost of immediate reconstruction is often far less to the patient. It can also reduce hospital costs by having fewer procedures and requiring a shorter length of the stay as an inpatient. [2] Additionally, immediate reconstruction often has a better cosmetic result because of the preservation of anatomic landmarks and skin. [3] With regards to psychosocial outcomes, opinions on timing have shifted in favor of immediate reconstruction. Originally, delayed reconstruction was believed to provide patients with time to psychologically adjust to the mastectomy and its effects on body image. However, this opinion is no longer widely held. [3] Compared to delayed procedures, immediate reconstruction can have a more positive psychological impact on patients and their self-esteem, most likely due to the post-operative breast more closely resembling the natural breast compared to the defect left by mastectomy alone. [2]

Delayed reconstruction

Delayed breast reconstruction is considered more challenging than immediate reconstruction. Frequently not just breast volume, but also skin surface area needs to be restored. Many patients undergoing delayed breast reconstruction have been previously treated with radiation or have had a reconstruction failure with immediate breast reconstruction. In nearly all cases of delayed breast reconstruction tissue must be borrowed from another part of the body to make the new breast. [4] Patients expected to receive radiation therapy as part of their adjuvant treatment are also commonly considered for delayed autologous reconstruction due to significantly higher complication rates with tissue expander-implant techniques in those patients. [2] While waiting to begin breast reconstruction until several months after radiation therapy may decrease the risk of complications, this risk will always be higher in patients who have received radiation therapy. [2] As with many other surgeries, patients with significant medical comorbidities (e.g., high blood pressure, obesity, diabetes) and smokers are higher-risk candidates. [2] Surgeons may choose to perform delayed reconstruction to decrease this risk.

Techniques

There are several techniques for breast reconstruction. These options are broadly categorized into two different groups:

Breast reconstruction using a tissue expander, which is later replaced by a permanent prosthetic implant. Blausen 0138 BreastReconstruction Expander.png
Breast reconstruction using a tissue expander, which is later replaced by a permanent prosthetic implant.

Implant-based reconstruction

This is the most common technique used worldwide. Implant-based reconstruction is an option for patients who have sufficient skin after mastectomy to cover a prosthetic implant and allow for a natural shape. For women undergoing bilateral mastectomies, implants provide the greatest opportunity for symmetrical shape and lift. Additionally, these procedures are generally much faster than flap-based reconstruction since tissue does not have to be taken from another part of the patient's body. [3]

Implant-based reconstruction may be one- or two-staged. [5] In one-stage reconstruction, a permanent implant is inserted at the time of mastectomy. During two-stage reconstruction, the surgeon will insert a tissue expander underneath the pectoralis major muscle of the chest wall at the time of mastectomy. [6] [7] This temporary silastic implant is used to hold tension on the mastectomy flaps. In doing so, the tissue expander prevents the breast tissue from contracting and allows for use of a larger implant later on compared to what would be safe at the time of the mastectomy. [3] Following this initial procedure, the patient must return to the clinic on multiple occasions for saline to be injected into a tube inside the tissue expander. By doing this slowly over the course of several weeks, the space beneath the pectoralis major muscle is safely expanded to an appropriate size without causing too much stress on the breast tissue. A second procedure is then necessary to remove the tissue expander and replace it with the final, permanent prosthetic implant. [8]

A permanent prosthetic implant eventually replaces the tissue expander. Blausen 0139 BreastReconstruction Prosthesis.png
A permanent prosthetic implant eventually replaces the tissue expander.

Although in the past, prosthetic implants were placed directly under the skin, this method has fallen out of favor because of the greater risk of complications, including visible rippling of the implant and capsular contracture. [3] The sub-pectoral technique described above is now preferred because it provides an additional muscular layer between the skin and the implant, decreasing the risk of visible deformity. [3] Oftentimes, however, the pectoralis major muscle is not sufficiently large enough to cover the inferior portion of the prosthetic implant. If this is the case, one option is to use an acellular dermal matrix to cover the exposed portion of the prosthetic implant, improving both functional and aesthetic outcomes. [9] [10] This prepectoral space has recently, however, come back into practice, with comparable rates of post-operative complications and implant loss to submuscular placement. [11] [12] Both delayed and direct-to-implant reconstruction in this plane has been shown to be favourable. [13]

Of note, a Cochrane review published in 2016 concluded that implants for use in breast reconstructive surgery have not been adequately studied in good quality clinical trials. "These days - even after a few million women have had breasts reconstructed – surgeons cannot inform women about the risks and complications of different implant-based breast reconstructive options on the basis of results derived from Randomized Controlled Trials." [14] [15]

Flap-based reconstruction

Flap-based reconstruction uses tissue from other parts of the patient's body (i.e., autologous tissue) such as the back, buttocks, thigh or abdomen. [16] In surgery, a "flap" is any type of tissue that is lifted from a donor site and moved to a recipient site using its own blood supply. Usually, the blood supply is a named vessel. Flap-based reconstruction may be performed either by leaving the donor tissue connected to the original site (also known as a pedicle flap) to retain its blood supply (where the vessels are tunneled beneath the skin surface to the new site) or by cutting the donor tissue's vessels and surgically reconnecting them to a new blood supply at the recipient site (also known as a free flap or free tissue transfer). [17] The latissimus dorsi is a prime example of such a flap since it can remain attached to its primary blood source which preserves the skins functioning, and is associated with better outcomes in comparison to other muscle and skin donor sites.   [18]

Transverse Rectus Abdominis Myocutaneous flap (TRAM). Blausen 0140 BreastReconstruction TRAM.png
Transverse Rectus Abdominis Myocutaneous flap (TRAM).

One option for breast reconstruction involves using the latissimus dorsi muscle as the donor tissue. [16] As a back muscle, the latissimus dorsi is large and flat and can be used without significant loss of function. It can be moved into the breast defect while still attached to its blood supply under the arm pit (axilla). A latissimus flap is often used to recruit soft-tissue coverage over an underlying implant; however, if the latissimus flap can provide enough volume, then occasionally it is used to reconstruct small breasts without the need for an implant. The latissimus dorsi flap has a number of advantages, but despite the advances in surgical techniques, it has remained vulnerable to skin dehiscence or necrosis at the donor site (on the back). [3] The Mannu flap is a form of latissimus dorsi flap which avoids this complication by preserving a generous subcutaneous fat layer at the donor site and has been shown to be a safe, simple and effective way of avoiding wound dehiscence at the donor site after extended latissimus dorsi flap reconstruction. [19]

Post-operative state after Transverse Rectus Abdominis Myocutaneous flap(TRAM). Blausen 0141 BreastReconstruction TRAM PostOp.png
Post-operative state after Transverse Rectus Abdominis Myocutaneous flap(TRAM).

Another possible donor site for breast reconstruction is the abdomen. [16] The TRAM (transverse rectus abdominis myocutaneous) flap or its technically distinct variants of microvascular "perforator flaps" like the DIEP/SIEA flaps are all commonly used. In a TRAM procedure, a portion of the abdominal tissue, which includes skin, subcutaneous fat, minor muscles, and connective tissues, is taken from the patient's abdomen and transplanted to the breast site. Both TRAM and DIEP/SIEA use the abdominal tissue between the umbilicus (or "belly button") and the pubis. The DIEP flap and free-TRAM flap require advanced microsurgical technique and are less common as a result. Both can provide enough tissue to reconstruct large breasts and are a good option for patients who would prefer to maintain their pre-operative breast volume. These procedures are preferred by some breast cancer patients because removal of the donor site tissue results in an abdominoplasty (tummy tuck) and allow the breast to be reconstructed with one's own tissues instead of a prosthetic implant that uses foreign material. That said, TRAM flap procedures can potentially weaken the abdominal wall and torso strength, but they are generally well tolerated by most patients. [3] Perforator techniques such as the DIEP (deep inferior epigastric perforator) flap and SIEA (superficial inferior epigastric artery) flap require precise dissection of small perforating vessels through the rectus muscle and, thus, do not require removal of abdominal muscle. Because of this, these flaps have the advantage of maintaining the majority of abdominal wall strength.

Other donor sites for autologous breast reconstruction include the buttocks, which provides tissue for the SGAP and IGAP (superior and inferior gluteal artery perforator, respectively) flaps. [20] The purpose of perforator flaps (DIEP, SIEA, SGAP, IGAP) is to provide sufficient skin and fat for an aesthetic reconstruction while minimizing post-operative complications from harvesting the underlying muscles. DIEP reconstruction generally produces the best outcome for most women. [21] See free flap breast reconstruction for more information.

Mold-assisted reconstruction is a potential adjunctive process to help in flap-based reconstruction. By using a laser and 3D printer, a patient-specific silicone mold can be used as an aid during surgery, used as a guide for orienting and shaping the flap to improve accuracy and symmetry. [22]

Adjunctive procedures

To restore the appearance of the pre-operative breast, there are a few options regarding the nipple-areolar complex (NAC):

When looking at the entire process of breast reconstruction, patients typically report that NAC reconstruction is the least satisfying step. [3] Compared to a normal nipple, the reconstructed nipple often has less projection (how far the nipple extends beyond the breast mound) and lacks sensation. [3] In women who have undergone a single mastectomy with reconstruction, another challenge is aesthetically matching the reconstructed NAC to the native breast. [3]

Outcomes

The typical outcome of breast reconstruction surgery is a breast mound with a pleasing aesthetic shape, with a texture similar to a natural breast, but which feels completely or mostly numb for the woman herself. [1] This loss of sensation, called somatosensory loss or the inability to perceive touch, heat, cold, and pain, sometimes results in women burning themselves or injuring themselves without noticing, or not noticing that their clothing has shifted to expose their breasts. [1] "I can't even feel it when my kids hug me," said one mother, who had nipple-sparing breast reconstruction after a bilateral mastectomy. [1] The loss of sensation has long-term medical consequences, because it makes the affected women unable to feel itchy rashes, infected sores, cuts, bruises, or situations that risk sunburns or frostbite on the affected areas.

More than half of women treated for breast cancer develop upper quarter dysfunction, including limits on how well they can move, pain in the breast, shoulder or arm, lymphedema, loss of sensation, and impaired strength. [27] The risk of dysfunction is higher among women who have breast reconstruction surgery. [27] One in three have complications, one in five need further surgery and the procedure fails in 5%. [28]

Some methods have specific side effects. The transverse rectus abdominis myocutaneous (TRAM) flap method results in weakness and loss of flexibility in the abdominal wall. [29] Reconstruction with implants have a higher risk of long-term pain. [27]

Outcomes-based research on quality of life improvements and psychosocial benefits associated with breast reconstruction [30] [31] served as the stimulus in the United States for the 1998 Women's Health and Cancer Rights Act, which mandated that health care payer cover breast and nipple reconstruction, contralateral procedures to achieve symmetry, and treatment for the sequelae of mastectomy. [32] This was followed in 2001 by additional legislation imposing penalties on noncompliant insurers. Similar provisions for coverage exist in most countries worldwide through national health care programs.

See also

Related Research Articles

<span class="mw-page-title-main">Mastectomy</span> Surgical removal of one or both breasts

Mastectomy is the medical term for the surgical removal of one or both breasts, partially or completely. A mastectomy is usually carried out to treat breast cancer. In some cases, women believed to be at high risk of breast cancer have the operation as a preventive measure. Alternatively, some women can choose to have a wide local excision, also known as a lumpectomy, an operation in which a small volume of breast tissue containing the tumor and a surrounding margin of healthy tissue is removed to conserve the breast. Both mastectomy and lumpectomy are referred to as "local therapies" for breast cancer, targeting the area of the tumor, as opposed to systemic therapies, such as chemotherapy, hormonal therapy, or immunotherapy.

<span class="mw-page-title-main">Plastic surgery</span> Medical surgical specialty

Plastic surgery is a surgical specialty involving the restoration, reconstruction or alteration of the human body. It can be divided into two main categories: reconstructive surgery and cosmetic surgery. Reconstructive surgery includes craniofacial surgery, hand surgery, microsurgery, and the treatment of burns. While reconstructive surgery aims to reconstruct a part of the body or improve its functioning, cosmetic surgery aims at improving the appearance of it.

<span class="mw-page-title-main">Mammaplasty</span> Surgically modifying the appearance of the breast

Mammaplasty refers to a group of surgical procedures, the goal of which is to reshape or otherwise modify the appearance of the breast. There are two main types of mammoplasty:

  1. Augmentation mammaplasty is commonly performed to increase the size, change the shape, and/or alter the texture of the breasts. This usually involves the surgical implantation of breast implant devices.
  2. Reduction mammaplasty is commonly performed to reduce the size, change the shape, and/or alter the texture of the breasts. This involves the removal of breast tissue.

Tissue expansion is a technique used by plastic, maxillofacial and reconstructive surgeons to cause the body to grow additional skin, bone, or other tissues. Other biological phenomena such as tissue inflammation can also be considered expansion.

Phalloplasty is the construction or reconstruction of a penis or the artificial modification of the penis by surgery. The term is also occasionally used to refer to penis enlargement.

Gender-affirming surgery for female-to-male transgender people includes a variety of surgical procedures that alter anatomical traits to provide physical traits more comfortable to the trans man's male identity and functioning.

<span class="mw-page-title-main">Breast augmentation</span> Surgical procedure

Breast augmentation and augmentation mammoplasty is a cosmetic surgery technique using breast-implants and fat-graft mammoplasty techniques to increase the size, change the shape, and alter the texture of the breasts. Augmentation mammoplasty is applied to correct congenital defects of the breasts and the chest wall. As an elective cosmetic surgery, primary augmentation changes the aesthetics – of size, shape, and texture – of healthy breasts.

<span class="mw-page-title-main">Breast reduction</span> Plastic surgery procedure

Reduction mammoplasty is the plastic surgery procedure for reducing the size of large breasts. In a breast reduction surgery for re-establishing a functional bust that is proportionate to the woman's body, the critical corrective consideration is the tissue viability of the nipple–areola complex (NAC), to ensure the functional sensitivity and lactational capability of the breasts. The indications for breast reduction surgery are three-fold – physical, aesthetic, and psychological – the restoration of the bust, of the woman's self-image, and of her mental health.

<span class="mw-page-title-main">Reconstructive surgery</span> Surgery to restore form and function

Reconstructive surgery is surgery performed to restore normal appearance and function to body parts malformed by a disease or medical condition.

<span class="mw-page-title-main">Male chest reconstruction</span> Surgical procedure

Male chest reconstruction refers to any of various surgical procedures to masculinise the chest by removing breast tissue or altering the nipples and areolae. Male chest reconstruction may be performed in cases of gynecomastia and gender dysphoria. Transmasculine people may pursue chest reconstruction, also known as top surgery, as part of transitioning.

<span class="mw-page-title-main">Breast implant</span> Prosthesis used to change the size, shape, and contour of a persons breast

A breast implant is a prosthesis used to change the size, shape, and contour of a person's breast. In reconstructive plastic surgery, breast implants can be placed to restore a natural looking breast following a mastectomy, to correct congenital defects and deformities of the chest wall or, cosmetically, to enlarge the appearance of the breast through breast augmentation surgery.

Mastopexy is the plastic surgery mammoplasty procedure for raising sagging breasts upon the chest of the woman, by changing and modifying the size, contour, and elevation of the breasts. In a breast-lift surgery to re-establish an aesthetically proportionate bust for the woman, the critical corrective consideration is the tissue viability of the nipple-areola complex (NAC), to ensure the functional sensitivity of the breasts for lactation and breast-feeding.

G. Patrick Maxwell is a plastic surgeon and an assistant clinical professor of surgery at Vanderbilt University, based in Nashville, Tennessee, USA.

A DIEP flap is type of breast reconstruction where blood vessels, fat, and skin from the lower belly are relocated to the chest to rebuild breasts after mastectomy. DIEP stands for the deep inferior epigastric perforator artery, which runs through the abdomen. This is a type of autologous reconstruction, meaning one's own tissue is used.

<span class="mw-page-title-main">Flap (surgery)</span> Surgical procedure in which tissue is transferred with intact blood supply

Flap surgery is a technique in plastic and reconstructive surgery where any type of tissue is lifted from a donor site and moved to a recipient site with an intact blood supply. This is distinct from a graft, which does not have an intact blood supply and therefore relies on growth of new blood vessels. This is done to fill a defect such as a wound resulting from injury or surgery when the remaining tissue is unable to support a graft, or to rebuild more complex anatomic structures such as breast or jaw.

Perforator flap surgery is a technique used in reconstructive surgery where skin and/or subcutaneous fat are removed from a distant or adjacent part of the body to reconstruct the excised part. The vessels that supply blood to the flap are isolated perforator(s) derived from a deep vascular system through the underlying muscle or intermuscular septa. Some perforators can have a mixed septal and intramuscular course before reaching the skin. The name of the particular flap is retrieved from its perforator and not from the underlying muscle. If there is a potential to harvest multiple perforator flaps from one vessel, the name of each flap is based on its anatomical region or muscle. For example, a perforator that only traverses through the septum to supply the underlying skin is called a septal perforator. Whereas a flap that is vascularised by a perforator traversing only through muscle to supply the underlying skin is called a muscle perforator. According to the distinct origin of their vascular supply, perforators can be classified into direct and indirect perforators. Direct perforators only pierce the deep fascia, they don't traverse any other structural tissue. Indirect perforators first run through other structures before piercing the deep fascia.

Free-flap breast reconstruction is a type of autologous-tissue breast reconstruction applied after mastectomy for breast cancer, without the emplacement of a breast implant prosthesis. As a type of plastic surgery, the free-flap procedure for breast reconstruction employs tissues, harvested from another part of the woman's body, to create a vascularised flap, which is equipped with its own blood vessels. Breast-reconstruction mammoplasty can sometimes be realised with the application of a pedicled flap of tissue that has been harvested from the latissimus dorsi muscle, which is the broadest muscle of the back, to which the pedicle (“foot”) of the tissue flap remains attached until it successfully grafts to the recipient site, the mastectomy wound. Moreover, if the volume of breast-tissue excised was of relatively small mass, breast augmentation procedures, such as autologous-fat grafting, also can be applied to reconstruct the breast lost to mastectomy.

<span class="mw-page-title-main">Nipple prosthesis</span>

Nipple/Areola prostheses are made of silicone by breast prosthesis manufacturers and anaplastologists for breast cancer survivors who were treated for breast cancer with a mastectomy. Prostheses can be worn weeks after a mastectomy, breast reconstruction, or even nipple reconstruction. As an inexpensive and convenient alternative to surgery, patients may choose to wear them anytime during treatment. Patients who ultimately find nipple prostheses thought that they should be informed of them during the consultation prior to mastectomy.

A preventive mastectomy or prophylactic mastectomy or risk-reducing mastectomy (RRM) is an elective operation to remove the breasts so that the risk of breast cancer is reduced.

<span class="mw-page-title-main">Nipple reconstruction surgery</span>

Nipple reconstruction, specifically nipple-areola complex (NAC) reconstruction, is a procedure commonly done for patients who had part or all of their nipple removed due to medical reasons. For example, NAC reconstruction can apply to breast cancer patients who underwent a mastectomy, the surgical removal of a breast. NAC reconstruction can also be applied to patients with trauma, burn injuries, and congenital or pathological abnormalities in nipple development.

References

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  16. 1 2 3 "Flap Procedures | Breast Reconstruction Using Your Own Tissue". www.cancer.org. Retrieved 2023-04-05.
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  19. ↑ Mannu GS, Farooq N, Down S, Burger A, Hussien MI (May 2013). "Avoiding back wound dehiscence in extended latissimus dorsi flap reconstruction". ANZ Journal of Surgery. 83 (5): 359–364. doi:10.1111/j.1445-2197.2012.06292.x. PMID   23088555. S2CID   32228590.
  20. ↑ Allen RJ, LoTempio MM, Granzow JW (May 2006). "Inferior Gluteal Perforator Flaps for Breast Reconstruction". Seminars in Plastic Surgery. 20 (2): 089–094. doi:10.1055/s-2006-941715. ISSN   1535-2188. PMC   2884781 .
  21. ↑ Erić M, Mihić N, Krivokuća D (2009-03-01). "Breast reconstruction following mastectomy; patient's satisfaction". Acta Chirurgica Belgica. 109 (2): 159–166. doi:10.1080/00015458.2009.11680398. PMID   19499674. S2CID   42474582.
  22. ↑ Melchels F, Wiggenhauser PS, Warne D, Barry M, Ong FR, Chong WS, et al. (September 2011). "CAD/CAM-assisted breast reconstruction" (PDF). Biofabrication. 3 (3): 034114. Bibcode:2011BioFa...3c4114M. doi:10.1088/1758-5082/3/3/034114. PMID   21900731. S2CID   206108959. Archived (PDF) from the original on 2022-10-09.
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  24. 1 2 Sisti A, Grimaldi L, Tassinari J, Cuomo R, Fortezza L, Bocchiotti MA, et al. (April 2016). "Nipple-areola complex reconstruction techniques: A literature review". European Journal of Surgical Oncology. 42 (4): 441–465. doi:10.1016/j.ejso.2016.01.003. PMID   26868167.
  25. ↑ Garramone CE, Lam B (May 2007). "Use of AlloDerm in primary nipple reconstruction to improve long-term nipple projection". Plastic and Reconstructive Surgery. 119 (6): 1663–1668. doi:10.1097/01.prs.0000258831.38615.80. PMID   17440338. S2CID   12604613.
  26. ↑ Darby A (24 October 2013). "3D Nipple Tattooing a New Service?". CosmeticTattoo.org Educational Articles.
  27. 1 2 3 McNeely ML, Binkley JM, Pusic AL, Campbell KL, Gabram S, Soballe PW (April 2012). "A prospective model of care for breast cancer rehabilitation: postoperative and postreconstructive issues". Cancer. 118 (8 Suppl): 2226–2236. doi:10.1002/cncr.27468. PMID   22488697. S2CID   205665309.
  28. ↑ Rabin RC (20 June 2018). "One in Three Women Undergoing Breast Reconstruction Have Complications". The New York Times. Retrieved 2018-06-21.
  29. ↑ Atisha D, Alderman AK (August 2009). "A systematic review of abdominal wall function following abdominal flaps for postmastectomy breast reconstruction". Annals of Plastic Surgery. 63 (2): 222–230. doi:10.1097/SAP.0b013e31818c4a9e. PMID   19593108. S2CID   9007020.
  30. ↑ Harcourt DM, Rumsey NJ, Ambler NR, Cawthorn SJ, Reid CD, Maddox PR, et al. (March 2003). "The psychological effect of mastectomy with or without breast reconstruction: a prospective, multicenter study". Plastic and Reconstructive Surgery. 111 (3): 1060–1068. doi:10.1097/01.PRS.0000046249.33122.76. PMID   12621175. S2CID   1445626.
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  32. ↑ "Your Rights After A Mastectomy... Women's Health & Cancer Rights Act of 1998". U.S. Department of Labor. January 15, 2009. Archived from the original on 2009-01-16.
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