Breast Reconstruction Following Mastectomy: Indications, Techniques, and ResultsHakim K. Said, MD, FACS, Sara H. Javid, MD, Shannon Colohan, MD, Otway Louie, MD, David W. Mathes, MD, Benjamin O. Anderson, MD, and Peter C. Neligan, MD

Early treatment of breast cancer centered on removal of disease, prevention of recurrence, and life expectancy. Since then, early detection and multimodal treatment have proven very effective, and breast cancer is currently one of the most curable forms of cancer. Survival without breast restoration, however, has a dramatic negative impact on self-image and lifestyle. Advances in the quality of care have focused on quality of life after treatment, particularly on return-ing women to their former lives before they were diagnosed with cancer. Today, the options for restoring a breast are better than ever, with natural tissues, organic matrices, or synthetic implants, espe-cially when used in novel combinations.

INDICATIONS

The surgical treatment options for both noninvasive (ductal carci-noma in situ) and invasive breast cancer include breast-conserving surgery (lumpectomy) and mastectomy. Approximately 70% of patients with early-stage invasive breast cancer are candidates for and elect breast-conserving surgery, but many will require or choose mas-tectomy due to the extent of malignant disease in the breast, prior radiotherapy exposure, contraindication to or desire to avoid radio-therapy, and/or risk reduction for subsequent breast cancers. Various technical approaches to mastectomy differ primarily with respect to the amount of the skin envelope that is preserved.

A nonskin-sparing (standard) mastectomy is performed when a patient does not desire or cannot undergo immediate reconstruc-tion. A wide elliptical incision is made, excising the nipple areolar complex (NAC) and the skin overlying the tumor, ultimately leading to a long transverse or oblique scar. The goal should be to minimize postoperative skin redundancy that might interfere with the wearing

of a prosthesis. In contrast, in a skin-sparing mastectomy, the breast is removed through a much smaller circumareolar incision narrowly encompassing the NAC in order to preserve the skin envelope for the reconstructed breast mound. A newer variation of this skin-sparing approach is the nipple-sparing, or total skin-sparing, mastectomy. The nipple-sparing mastectomy, previously termed the subcutaneous mastectomy in the 1970s and 1980s, was an operation that fell into disrepute out of concern that excessive fibroglandular tissue would be left behind the NAC, but it is now being reevaluated for the purpose of cancer prophylaxis and in carefully selected breast cancer cases.

Because the perfusion to the skin and the nipple comes primarily from the breast that must be removed, the remaining skin may be relatively ischemic and prone to healing challenges. As the mastec-tomy plane grows closer to the skin, the chance increases of causing damage to the subdermal plexus that is the only remaining source of perfusion. Whereas in a standard mastectomy, this ischemic central breast skin would be removed, in skin-sparing mastectomy, most of these skin flaps are preserved. Nipple-sparing mastectomy leaves essentially all the breast skin intact, regardless of how far away the nearest intact blood vessels lie. This further increases the amount of ischemic skin, the chance of healing problems, and the risk of com-plications after either of these kinds of mastectomy. Reliably preserv-ing an intact and undamaged subdermal plexus is a challenge in skin-sparing mastectomy, and critically important in nipple-sparing mastectomy, in order to avoid complications after mastectomy. Moreover, while leaving fibroglandular tissue behind poses an onco-logic risk, excessively thinning the dermal subcutaneous tissue nega-tively impacts the appearance and quality of the reconstructive outcome.

In general, both skin-sparing and nipple-sparing mastectomies are only performed in the setting of breast reconstruction, whether that reconstruction is performed during the same operation or shortly thereafter as a separate procedure once the skin has recovered and the surgical pathology results are known.

Several studies have demonstrated that post-mastectomy breast reconstruction affords several benefits, including improved body image, psychological health, and reduced concern for cancer recur-rence. Although most patients are eligible to undergo reconstruction in a delayed fashion following completion of their breast cancer treatment, many patients are eligible to begin reconstruction at the time of their mastectomy (immediate reconstruction). The deci-sion to proceed with immediate reconstruction depends on patient and disease factors, as well as treatment-related factors. In some cases, the mastectomy is performed as a separate procedure, with recon-struction to be performed a few weeks later (delayed-immediate), in order to allow pathologic examination of the specimen before proceeding with the reconstructive procedure.

Immediate reconstruction, with either a prosthetic device or autologous tissue, requires a preserved skin envelope with a skin-sparing mastectomy. The majority of patients with early-stage (0, I, II) breast cancer can undergo this approach. Immediate

622 Breast reconstruction Following MastectoMy: indications, techniques, and results

mastectomy to permit construction of a full breast of the desired size. Second, the mastectomy skin must be of sufficient viability to tolerate the weight and expansion produced by a full-size implant. Third, the patients desired goals in terms of the final implant must be explicitly known and achievable at this point. Many patients lose enough skin through mastectomy to reduce the volume that can be reached, or they have delicate skin flaps that would be compromised by or even necrose as a result of excessive tension from a full-size implant. Patients generally are better served by placement of an adjustable expander with a lower fill volume and a two-stage reconstruction. In addition, the second stage implant exchange allows the patient to choose her desired implant size and type and allows for another chance to adjust the pocket for a more optimal breast shape.

Tissue Matrices

Offered by a number of manufacturers, tissue matrices are organic substrates derived from human, porcine, or bovine origins, processed to produce an implantable organic scaffold. They are commonly placed in conjunction with an expander at the time of mastectomy as a sling, which offloads the skin by bearing the weight of the implant. In addition, these matrices allow a significant degree of control over the size and shape of the implant pocket, including definitive positioning of the inframammary fold. Evidence suggests they may have a beneficial effect on capsular contracture rates, which are especially high among patients who have undergone radiation (Figure 2).

Autologous Methods of Breast Reconstruction

Some women do not like the idea of having implants, while others, for any number of reasons, may not be candidates for that type of reconstruction. The most common reason that a patient may not be eligible for implant reconstruction is because of a history of radia-tion. Using the patients own tissues to reconstruct the entire breast is an attractive option for these patients. Natural tissue has the poten-tial to provide durable reconstruction of the full breast volume, often without the vulnerability of implants, which can fail or require replacement eventually.

reconstruction is contraindicated in a patient with skin involvement, such as skin ulceration (T4b) or inflammatory (T4d) breast cancer. In addition, if a patient is expected to require post-mastectomy radia-tion therapy (PMRT), such as those with locally advanced (stage III) cancers, immediate reconstruction with autologous tissue is to be avoided to prevent the deleterious effects of radiation on the recon-struction. However, in such cases, skin-sparing mastectomy with immediate reconstruction using a temporary prosthesis (tissue expander) is often possible, with the understanding that this expander may need to be deflated prior to radiation. Other relative contrain-dications for immediate reconstruction include active smoking history and medical comorbidities such as morbid obesity or cardio-pulmonary disease.

RECONSTRUCTIVE TECHNIQUES

Women who elect to undergo reconstruction have two main recon-structive options: prosthetic devices (tissue expanders, implants) or autologous tissue reconstruction using tissue transferred from a distant donor site to the chest wall. The choice can sometimes be driven by the breast cancer treatment plan, such as patients who will require PMRT, which largely eliminates the option of immediate autologous reconstruction. More commonly, reconstruction reflects the patients choice and the reconstructive surgeons recommenda-tion. For instance, very slender women may not have ample donor tissue available for autologous reconstruction, and women with a history of prior radiation (e.g., mantle radiation for lymphoma) may not be candidates for implant-based reconstruction because of the significantly higher risk of implant complications in a radiated setting.

Implants

Implants are selected by many women because of the desire to avoid a second surgical scar and recovery associated with the donor site or because it entails less extensive surgery. Downsides of implant-based reconstruction include higher risk of infection due to presence of a foreign body, risk of capsular contracture, and risk of leak or rupture, which would require removal or replacement.

Two Stages

Historically, the two-stage implant approach is the earliest form of breast reconstruction, although implants have gone through many iterations. Today the great majority of implants are placed in two stages. First, an adjustable implant called an expander is placed sub-pectorally, either deflated or partially filled. Typically, over the next 3 months, the expander is inflated with saline on a weekly basis to reach an appropriate goal size. At that point, the expander is replaced by a softer and more aesthetic implant, saline or silicone. Although in the United States, between 1994 and 2007, a moratorium prohibited use of silicone gel implants, elsewhere in the world their use has contin-ued. In 2007, the safety data were convincing enough to warrant rerelease of silicone gel implants on the U.S. market. Subsequent studies have documented significantly improved patient satisfaction and better aesthetic outcomes in the setting of breast reconstruction using silicone gel implants versus saline implants. Most patients cur-rently choose the silicone implants, and the outcomes are closer to the results obtained with autologous reconstruction (Figure 1).

One Stage

An alternative to this approach is one-stage reconstruction using a permanent silicone implant placed subpectorally at the time of the mastectomy. This reduces the number of surgeries required but poses several risks. First, there must be sufficient skin redundancy after

FIGURE 1 Implantreconstruction.

the Breast 623

rotated from the back to the chest. The skin paddle of the latissimus can be oriented obliquely or transversely to hide the donor site scar under the bra line. In most cases, the latissimus flap is combined with placement of a breast implant, as there usually is insufficient bulk to create a breast mound. This is particularly useful in patients who have been through radiation treatments. The addition of nonradiated tissue from the back can make implant reconstruction possible in patients who otherwise might not be candidates for implants.

TheTRAMFlap

Introduced by Hartrampf, the TRAM flap takes advantage of the blood supply of the abdominal skin. Based on the superior epigastric artery, an ellipse of lower abdominal skin and fat, along with underly-ing rectus abdominis muscle, is mobilized. This flap is tunneled from the abdomen into the chest, where it is folded and inset to reproduce the breast shape. The abdominal donor site is treated similarly to a tummy tuck, by undermining the upper abdominal skin and advanc-ing it to facilitate closure. Critics of the pedicled TRAM flap point out that, with sacrifice of one or both rectus muscles, there is signifi-cant potential weakening of the abdominal wall and careful recon-struction of the abdomen to prevent future development of a ventral hernia is critical.

Free Flap Breast Reconstruction

Free flap breast reconstruction has undergone an evolution over the past 20 years. Because of concerns with abdominal wall integrity following pedicled TRAM flap reconstruction, the free TRAM was developed, based on the deep inferior epigastric vessels. The rationale was that less muscle could be harvested, and the expectation was that donor morbidity would be less. As our knowledge of vascular anatomy improved, the free TRAM became the muscle-sparing free TRAM, harvesting less and less muscle. Ultimately, with the intro-duction of perforator flaps, we learned how to dissect the vascular pedicle out of the rectus muscle with minimal disruption of the muscle and preservation of the segmental nerves. This evolved to become the deep inferior epigastric perforator (DIEP) flap (Figure 3). In each of these flaps, the major pedicle, the deep inferior epigas-tric artery, is divided and reanastomosed in the chest to the internal mammary vessels.

In patients who are not candidates for abdominal-flap breast reconstruction, either because of insufficient tissue availability or because of previous surgery, there are several other options. These include the transverse upper gracilis (TUG) flap (Figure 4), which includes skin and subcutaneous fat from the upper inner thigh, or the superior and inferior gluteal artery perforator (SGAP and IGAP) flaps. Each relies on a donor site and removal of excess tissue at a respective site on the patient. All of these flaps require advanced microsurgical expertise as well as an intimate knowledge of the vas-cular anatomy of the flap involved based on preoperative computed tomographic scan imaging evaluation. Each donor site also repre-sents a particular set of benefits or drawbacks depending on the site and the patient.

There are many ways to reconstruct a breast using autologous tissue. All involve incisions for harvesting tissues from various donor sites elsewhere on the body. These methods can be divided into three broad categories: (1) fat grafting, (2) pedicled flap reconstruction, and (3) free flap reconstruction. The last of these requires microsur-gical skills.

Fat Grafting

The use of fat grafting in breast reconstruction is a relatively new technique. Fat grafting has been used in aesthetic surgery for a number of years. Structural fat grafting involves harvesting adipose tissue from other areas on the body through a series of tiny nick incisions. Small amounts of fat are carefully prepared and then injected in multiple planes into areas to be treated. Depending on the site, 30% to 70% of the fat injected with this technique can be retained and engrafted long-term. Overcorrection, subsidence, and retreatment are the keys to reaching the goal size with this method. It is an extremely useful technique for reconstruction of lumpectomy defects, where one treatment may be all that is necessary (Petit et al., 2011).

It has also gained favor for contour correction and volume adjust-ment in conjunction with implant reconstruction. Some of the issues associated with implants, such as implant rippling or edge step-off deformities, can be addressed easily with lipofilling using fat har-vested from other sites of redundancy, without significant scars or deformity at the donor sites.

More recently, Khouri has introduced the concept of external expansion using a suction cup device worn by women called the Brava bra (BRAVA LLC, Miami, Fla). This expands the recipient site, creating an edematous mound that can accommodate larger volumes of fat injection. Typically, patients will undergo 3 to 4 sessions of fat grafting over a number of months, in conjunction with a regimen of external expansion before and after each surgery. With persistence, the entire breast mound can be reconstructed to a reasonable volume with repeated rounds of this method.

Pedicled Flap Reconstruction

A pedicled flap is one in which the vascular supply remains intact and is transferred into the breast from an adjacent region. The two most common pedicled flaps in use for breast reconstruction are the latissimus dorsi myocutaneous flap and the transverse rectus abdom-inis myocutaneous (TRAM) flap. Other flaps exist based on perfora-tors from the thoracodorsal vessels and the intercostal vessels. These will be discussed later. Many of these flaps are also extremely useful for reconstructing partial mastectomy defects or defects resulting from lumpectomy.

TheLatissimusFlap

The blood supply of the latissimus dorsi is from the thoracodorsal artery. Because of the favorable position of this pedicle, the latissimus muscle and its overlying skin can be pivoted on the pedicle and

FIGURE 2 One-stageimplantreconstructionwithtissuematrix.

624 Breast reconstruction Following MastectoMy: indications, techniques, and results

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Salzberg CA: Focus on technique: one-stage implant-based breast reconstruc-tion, Plast Reconstr Surg 130(5 Suppl 2):95S103S, 2012.

Wagner JL, Fearmonti R, Hunt KK, et al: Prospective evaluation of the nipple-areola complex sparing mastectomy for risk reduction and for early-stage breast cancer, Ann Surg Oncol 19(4):11371144, 2012.

Warren Peled A, Foster RD, Stover AC, et al: Outcomes after total skin-sparing mastectomy and immediate reconstruction in 657 breasts, Ann Surg Oncol 19(11):34023409, 2012.

S u g g e S t e d R e a d i n g SBoneti C, Yuen J, Santiago C, et al: Oncologic safety of nipple skin-sparing or

total skin-sparing mastectomies with immediate reconstruction, J Am Coll Surg 212(4):686693; discussion 693685, 2011.

Khouri RK, Eisenmann-Klein M, et al: Brava and autologous fat transfer is a safe and effective breast augmentation alternative: results of a 6-year, 81-patient, prospective multicenter study, Plast Reconstr Surg 129(5):11731187, 2012.

Lambert K, Mokbel K: Does post-mastectomy radiotherapy represent a con-traindication to skin-sparing mastectomy and immediate reconstruction: an update, Surg Oncol 21(2):e67e74, 2012.

Laronga C, Lewis JD, Smith PD: The changing face of mastectomy: an onco-logic and cosmetic perspective, Cancer Control 19(4):286294, 2012.

FIGURE 4 Delayedtransverseuppergracilis(TAG)flapreconstruction.

FIGURE 3 Immediatedeepinferiorepigastricperforator(DIEP)flapreconstruction.

Breast Reconstruction Following Mastectomy:IndicationsReconstructive TechniquesImplantsTwo StagesOne StageTissue Matrices

Autologous Methods of Breast ReconstructionFat GraftingPedicled Flap ReconstructionThe Latissimus FlapThe TRAM Flap

Free Flap Breast Reconstruction

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