Why breast reconstruction is important?
I. Why Breast Reconstruction is Important?
Breast reconstruction is not just cosmetic surgery. A woman who has lost a breast is missing a body part, and is no longer symmetric. Despite the use of an external prosthesis, the absence of a breast can interfere with wearing of clothing and with some physical activities. It can also cause psychological and emotional harm. Breast reconstruction does not really restore the missing breast, but it usually does allow the patient to wear normal clothing, feel more normal, and carry on her daily activities without being constantly reminded that she is a cancer patient.
II. Timing of Breast Reconstruction
Breast reconstruction can be performed at the same time as the mastectomy (immediate reconstruction) or months or years later when the patient chooses to undergo reconstruction at a later time (delayed reconstruction). We generally prefer immediate reconstruction when possible because it is more convenient for the patient, requires one less general anesthetic, is less expensive, and can provide better aesthetic results. This is especially true when some of the uninvolved breast skin can be preserved for use in the reconstruction, using what is called a "skin-sparing mastectomy" (Figure 1). Provided that the tumor is not close to the skin, skin-sparing mastectomy does not increase the risk of recurrent cancer and can contribute significantly to the aesthetic success of the reconstruction.
Delayed reconstruction can be very successful and even as good as immediate reconstruction in some cases (Figure 2). However, the aesthetic results are not as consistent as they are in immediate reconstruction. If the patient has also had previous irradiation there may be a significant amount of scar tissue that will make reconstruction more difficult and the aesthetic result less certain. Nevertheless, delayed reconstruction is far better than no reconstruction at all.
III. Types of Breast Reconstruction
Missing breast skin can only be replaced with the patient's own skin, either by expanding (stretching) remaining skin already present on the chest wall or by transferring it from somewhere else using a flap. The missing breast tissue volume, however, can be replaced either by a prosthetic implant or by the patient's own tissues (autologous tissues). Each of these two types of reconstruction has certain advantages and disadvantages. No one approach is ideal for all patients. Which method of reconstruction is chosen for any individual patient will depend on many factors, including preference of the patient, the surgeon's training and experience, and the patient's physical condition.
A. Implant-Based Reconstruction
Reconstruction with implants is easier than reconstruction with autologous tissues, and requires less training and experience from the surgeon. The initial stages of the reconstruction are also much quicker and require less surgery. For this reason, implant-based reconstruction is usually the best choice for patients over age 65 and those who are not in good physical condition, who might have difficulty tolerating the longer operation required in the first stage of a reconstruction with autologous tissues. It may also be the best choice for patients without sufficient autologous tissue to make an adequate breast.
Sometimes, there is enough skin remaining on the chest wall that reconstruction can be achieved simply by inserting an implant. In most cases, however, extra skin needs to be generated by stretching the available, remaining skin. The most common method for doing this is with tissue expansion. In this technique, a balloon-like device (the tissue expander) is placed beneath whatever skin remains on the breast immediately following the mastectomy. Over the next 2 months, salt water (saline) is gradually injected into the expander at weekly intervals to fill it and stretch the overlying skin. When the skin has been sufficiently stretched and this stretching has been left long enough to become permanent (usually 4 to 6 months), the expander is removed and replaced by a more permanent device containing silicone gel or saline.
In many cases, reconstruction with tissue expansion and implant insertion works well (Figure 3). In time, however, most such reconstructions develop some degree of capsular contracture, which is a contraction of the scar-tissue capsule that always forms around the implant. When this occurs, the appearance of the reconstructed breast is affected (Figure 4) and the breast can in some cases become hard and painful.
The use of silicone gel implants gives a more natural feel than saline, but the risk of capsular contracture is higher. For that reason, and because the main problem with implant-based reconstruction is the high incidence of capsular contracture, many surgeons prefer saline implants for breast reconstruction.
Another commonly used method of breast reconstruction based on implants is the latissimus dorsi myocutaneous flap. In this technique, a flap of skin and muscle is taken from the back and transferred to the front of the chest where it is used to cover an implant. In most cases, tissue expansion is not necessary and the reconstruction can be completed in one stage. There is a scar on the back and the use of one latissimus dorsi muscle is lost. Nevertheless, most women are not significantly bothered by the donor site scar, and good results can be obtained (Figure 5).
The main disadvantage to the standard latissimus dorsi flap technique is that its success is totally dependent on the implant. If the patient develops capsular contracture, the patient will no longer have a soft, aesthetically pleasing breast. Although capsular contracture seems to be slightly less common after latissimus dorsi flaps than it is after tissue expansion, it remains a significant and unsolved problem.
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B. Reconstruction with Autologous Tissues
Reconstruction with autologous tissue solves the problem of capsular contracture because the breast volume is replaced by the patient's own skin and fat, so an implant is unnecessary. The breast is much softer and more natural than a breast reconstructed with an implant, and rather than getting worse with time (as implant-based reconstructions usually do) they improve. A successful breast reconstruction with autologous tissue often looks, moves, and feels much like a real breast.
Although the initial surgical procedure required to reconstruct a breast with autologous tissue is much longer and more complicated than that required for implant-based reconstruction, subsequent surgical procedures are simpler, shorter, and less frequent. In the long run, autologous tissue reconstruction usually requires no more (and sometimes less) time in the operating room and hospital than does reconstruction based on an implant. Because of this, and because the quality of the reconstruction is much better over the long term, we generally prefer autologous tissue breast reconstruction when that option is available.
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(1) Pedicled TRAM Flaps
The first successful method of breast reconstruction was the pedicled transverse rectus abdominis myocutaneous (TRAM) flap. In this operation, a wide ellipse of skin and fatty tissue is removed from the patient's lower abdomen, but left attached to one of the two rectus abdominis muscles. A tunnel is created between the abdominal dissection and the defect left by removal of the breast, and the flap is passed up onto the chest wall. The flap gets its blood supply from the superior epigastric artery and vein, which remain attached to it and keep it alive. Because a woman's abdomen is designed to stretch to accommodate pregnancy, the donor site can be closed with sutures. The flap is then shaped to form a facsimile of a breast.
The pedicled TRAM flap is capable of achieving very good results (Figure 6) and was a tremendous advance in the art of breast reconstruction. In certain patients, it still remains the technique of choice. In some patients, however, (especially those who are obese or who smoke) the blood supply of the pedicled TRAM flap can be insufficient, leading to partial flap loss and poor aesthetic results. This technique also requires sacrifice of at least one rectus abdominis muscle. For these reasons, some surgeons prefer another alternative, such as more recent versions of the TRAM flap.
The TRAM flap is not perfect, and is not always successful. Patients can have problems with postoperative abdominal weakness, bulging, or hernia. When properly performed, the incidence of significant complications is low. When the operation is not performed properly, however, complications can be severe and frequent.
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(2) Delayed Pedicled TRAM flap
One way to improve the blood supply to the TRAM flap is to perform a delay procedure one week before the actual reconstruction. In the delay procedure, the blood vessels that enter the flap from below are divided, encouraging the blood vessels that supply the flap from above to become larger. This requires a separate (minor) preliminary operation, but seems to be effective in reducing the risk of vascular insufficiency to the flap. Delay of the TRAM flap is particularly favored by reconstructive surgeons who are not comfortable performing free flaps. At the University of Texas M. D. Anderson Cancer Center, however, we perform many free flaps for a wide variety of indications and so delay of a TRAM flap is rarely used.
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(3) Free TRAM Flaps
The free TRAM flap gets its blood supply from below, from the deep inferior epigastric vessels (Figure 7). These blood vessels are divided and then reattached (using fine sutures and a microscope) to recipient vessels in the chest wall or in the axilla. The free TRAM flap has two advantages over the conventional, pedicled TRAM flap. First, the blood supply is more direct so that it is stronger and less likely to cause partial flap loss or fat necrosis. Secondly, only a small part of the rectus abdominis muscle need be sacrificed so there is less postoperative pain and abdominal wall weakness. Patients recover from the surgery more quickly and the aesthetic results tend to be better.
The main disadvantage of the free TRAM flap is its total dependence on the successful connection (anastomosis) of the blood vessels to maintain survival of the flap. If the anastomosis becomes obstructed and blood does not reach the flap, the tissue will die and the reconstruction will fail. In experienced hands, the failure rate is less than 2 percent. Failure is even less common in patients who are not obese. Still, successful reconstruction cannot ever be guaranteed and patients must accept the possibility (as with any type of reconstruction) that the reconstruction will fail.
Free TRAM flaps tend to have especially good aesthetic results because the excellent blood supply allows more aggressive shaping of the flap (Figures 8, 9). They also have a lower incidence of fat necrosis (areas of scar tissue caused by dead fat cells) than pedicled TRAM flaps. Free TRAM flap patients are also more likely to be able to do situps postoperatively than patients who have had pedicled TRAM flaps. For these reasons, many surgeons prefer to use this type of TRAM flap when the blood vessels are suitable.
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(4) DIEP (Perforator) Flaps
A relatively new variation of the TRAM flap is the deep inferior epigastric perforator (DIEP) flap. In this flap, the skin and fat island are identical to that of the TRAM flap but one, two, or three perforating blood vessels are dissected through the rectus abdominis muscle so that the muscle can be left in the abdomen rather than harvested with the flap. The DIEP flap therefore consists only of skin, fat, and blood vessels. No muscle is sacrificed (although some may be damaged), so the patient has less postoperative pain and a stronger abdominal wall. In appropriate patients, the results can be excellent (Figure 10).
The main disadvantage of this flap (aside from the technical complexity) is that the blood supply to the flap is reduced somewhat and fat necrosis and partial flap loss are more common than after standard free TRAM flaps. For this reason, we prefer to limit the use of the DIEP flap to patients in whom only 65% or less of the TRAM flap skin island will be needed to make the breast. Using this approach, fat necrosis and partial flap loss have been less common than in our early experience with this flap. It is fair to say, however, that the place of the DIEP flap in breast reconstruction is still evolving and there is not yet agreement among plastic surgeons about the indications for its use.
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(5) The S-GAP Flap
Another type of perforator flap that has recently been described is the superior gluteal artery perforator (S-GAP) flap. In this variation of the superior gluteal free flap, taken from the buttock, a single perforator is identified and dissected through the gluteus maximus muscle until it joins the superior gluteal artery and vein. These vessels are then ligated and divided, leaving a flap that consists only of skin, fat, and blood vessels. The flap is transferred to the chest and anastomosed to the internal mammary vessels like a free TRAM flap. It is then shaped into a breast (Figure 11).
No muscle is sacrificed, and the donor site is acceptable (Figure 12). The disadvantage of this flap is that is technically more difficult than a TRAM flap, and the gluteal tissue is a bit harder to shape into a breast. For patients who are not suitable candidates for a TRAM flap, however, this can be a good alternative.
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(6) Extended Latissimus Dorsi Flaps
Another alternative for patients who are not good candidates for a TRAM flap is the extended latissimus dorsi flap. In this flap, the standard latissimus dorsi flap is modified to that additional skin and fat are removed from the back and transferred to the chest. The donor site on the back is more scarred than after a standard latissimus dorsi flap, but in most cases the breast can be reconstructed without an implant. The breasts are therefore softer than after a standard latissimus dorsi reconstruction, and the risk of capsular contracture is avoided.
The main advantage of this flap over a TRAM flap is that it is a simpler technique and can be used in less healthy patients who might not be good enough surgical candidates to have a TRAM flap. It is therefore particularly indicated in very obese patients (Figure 13) and in older patients. Although poor surgical candidates should not have any reconstruction, some patients who are not healthy enough to undergo a TRAM flap are adequate candidates for an extended latissimus dorsi flap.
This flap is also a reasonable choice for healthy patients who cannot have a TRAM flap because they have had a previous TRAM flap or abdominoplasty. Patients in this category may also be good candidates for a gluteal free flap. The choice between these donor sites is usually made after considering the relative laxity of tissues in the back versus the buttock in each individual, as well as patient preferences.
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(7) Inferior Gluteal Free Flap
Another alternative for autologous tissue breast reconstruction is the inferior gluteal free flap. This flap is taken from the lower buttock and is based on the inferior gluteal vessels. It requires sacrifice of a small amount of the gluteus maximus muscle, and is technically more difficult than a TRAM flap. It is capable, however, of achieving excellent results (Figure 14). Like the S-GAP flap, it is mainly indicated in patients who cannot have a TRAM flap because of previous surgery but who are otherwise good surgical candidates.
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(8) Other Flaps
Other free flaps which have been used successfully for breast reconstruction include the Rubens Fat Pad Flap, the superior gluteal myocutaneous free flap, the lateral thigh flap, the gracilis flap, and the superficial inferior epigastric flap. All these techniques have advantages and indications, but because they are rarely used will not be described here.
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Despite the surgeon's best efforts to achieve symmetry in the first operation, almost all patients will need at least one revision of their breast mound reconstruction to achieve reasonable breast symmetry. These revisions should be considered an integral part of the reconstruction process, and both patients and their insurance companies should expect them. Most revisions can be performed as an out-patient under local anesthesia, and the surgery is minor compared to the magnitude of a TRAM flap. With revisions, breast symmetry and the aesthetic result of the reconstruction can be significantly improved. Even after revision, the result will rarely be perfect but in most cases the symmetry is good enough that the patient will look normal in her clothing (or even a bathing suit) and will be satisfied.
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V. Nipple Reconstruction
Nipple reconstruction is usually performed only after the breast shaping has been completed. The most important part of nipple reconstruction is its location. Even the best nipple will not look right if it is in the wrong place. Although there are many techniques for nipple reconstruction, most modern techniques use local flaps of skin and fat to create a projecting nub, and do not require any type of grafting. Tattooing is used to pigment the nipple and create the areola. Nipple reconstruction can be performed in the office or clinic, under local anesthesia. In this way it can be kept simple, inexpensive, convenient, and relatively painless. Although the results of nipple reconstruction are not perfect, the presence of a reconstructed nipple does contribute significantly to the illusion of having re-created a normal breast (Figure 15). Patients are therefore encouraged to undergo nipple reconstruction and complete the process of breast reconstruction whenever possible.