Breast reconstruction

Goals

• Produce a breast mound that fulfils the patient's wishes and matches the contralateral breast

Risks/contraindications

• Absolute
  • Serious medical comorbidities
  • Unresectable chest wall disease
  • Uncontrolled metastatic disease
• Relative
  • Smoking - much higher rate of complications - mostly not offered reconstruction
  • Obesity BMI >25 - increased risks and harder to achieve a breast mound with adequate volume and definition
  • Larger breast size
  • Radiotherapy - worse for non-autologous reconstruction

Timing

• Patient preference is important
• No change to long-term survival, local recurrence, or detection of local recurrence
• Need to plan this carefully in MDM from the start, anticipating the need for radiotherapy and adjuvant chemotherapy

Immediate

• • Fewer operations, no time without breasts
  • Skin-sparing/nipple-sparing techniques are oncologically safe
  • Multiple surgeons involved with longer operative time
  • Limited time for decision-making
  • Doesn't usually compromise adjuvant treatment
  • I think this is the default approach where there aren't contraindications
  • Contraindications
    • Absolute:
      • Inflammatory breast cancer
      • Poorly-controlled comorbidities/smoking
    • Relative:
      • Stage III disease or higher
      • Need for radiation

Delayed

• • Fewer complications
  • More time to decide
  • Better for those requiring radiation or smokers
  • Mastectomy skin flaps can heal, and any issues can be revised at reconstruction
  • Inferior cosmetic outcome, as a larger area of skin is required to be brought into the reconstruction
  • Autologous reconstruction is typically indicated
  • Second major operation required

Delayed-immediate

• • Skin-sparing mastectomy and place tissue expander, then return for autologous reconstruction after radiation
  • If pathology shows no need for post-mastectomy radiotherapy, can proceed to reconstruction rapidly

Techniques

Non-autologous

• • Advantages/disadvantages
    • Shortest operating time, inpatient stay and fastest recovery
    • Hard to achieve symmetry, especially with large ptotic breasts, unless a contralateral augmentation or mastopexy is performed
    • Hard to do with radiotherapy - significantly increases complications
  • Best technique for:
    • Small to moderate sized breasts
    • Minimal ptosis
    • No radiotherapy
    • Previously augmented patient
    • Bilateral mastectomy
  • Tissue expander then change to implant
    • Often placed in submuscular plane
    • Six months after finishing radiotherapy, or 2-3 months later if no radiotherapy
  • Direct-to-implant
    • One-stage may be appropriate in fit patients with minimal risk factors for healing

Autologous reconstruction

• • More natural appearance, feel and durability
  • Can be done immediate or delayed
  • Best technique for:
    • Moderate to large breast size with ptosis
    • Suitable donor sites
    • Radiotherapy has been given or is planned
  • Latissimus myocutaneous flap
    • Based on thoracodorsal vessels, tunnelled through axilla
    • Either muscle-only, or muculocutaneous
    • Technique
      • Dissect on LD anterior border, then find thoracodorsal pedicle
      • Fashion a high axillary tunnel
      • Transfer pedicle to mastectomy wound
    • Advantages - natural look, increases/decreases in proportion to body fat composition (more than TRAM and DIEP), ages with patient
    • Disadvantage - latissimus dorsi weakness, longer surgery, more than one scar
  • TRAM - transverse rectus abdominis myocutaneous flap
    • Pedicled TRAM is just rotated through into chest
    • Free TRAM is detached, reattached to vascular supply in chest
    • Often requires mesh reconstruction of abdo wall
    • Blood supply from deep superior epigastric
    • Advantage - natural look, increases/decreases in proportion to body fat composition, ages with patient
    • Disadvantage - abdominal weakness, disrupts abdominal wall planes, increased risk of abdominal hernia
  • DIEP - deep inferior epigastric perforator flap
    • Skin and fat of abdo wall
    • Blood supply off inferior epigastric vessels without removal/destruction of rectus muscle or fascia
    • Advantage - natural look, increases/decreases in proportion to body fat composition, ages with patient
    • Disadvantages - requires vascular anastomosis, risk of flap necrosis
  • SIEA - superficial inferior epigastric artery flap
    • Higher failure rate than others
  • Transverse upper gracilis flap (TUG)
    • Thigh free flap
    • Only works with small breasts
• Combination
• Symmetrising surgery
  • Mastopexy
  • Breast and skin reduction
  • Augmentation mammoplasty

Complications

• Local recurrence