Continuing Education Activity
Breast cancer is the most common cancer, and the second leading cause of cancer death, in women in the United States. Treatment has progressively improved with new advances in endocrine therapy, early detection, and breast conservation surgical techniques. However, for patients undergoing mastectomy, the additional concern of a deforming surgery after a cancer diagnosis plays a large factor in patients' treatment choices. It is the goal of the plastic surgeon, along with the patient and their breast surgeon, to develop a plan to restore the patient’s body image. Many factors play a role in the reconstruction process, and it is important to discuss all options with the patient to provide optimal results. From the timing of the procedure to procedure choice and use of chemoradiation, the entire scope of the cancer treatment must be considered before proceeding with reconstruction. This activity reviews the indications, contraindications of breast reconstruction and highlights the role of the interprofessional team in the pre- and post-operative management of these patients.
- Describe the techniques of breast reconstruction.
- Outline the indications for a breast reconstruction.
- Summarize the complications of breast reconstruction.
- Describe the importance of improving care coordination among interprofessional team members to improve outcomes for patients undergoing breast reconstruction.
Breast cancer is the most common cancer, and the second leading cause of cancer death, in women in the United States. Treatment has progressively improved with new advances in endocrine therapy, early detection, and breast conservation surgical techniques. However, for patients undergoing mastectomy, the additional concern of a deforming surgery after a cancer diagnosis plays a large factor in the patient’s treatment and overall psychosocial recovery. It is the goal of the plastic surgeon, along with the patient and their breast surgeon, to develop a plan to restore the patient’s body image once the oncologic treatment has been successful. Many factors play a role in the reconstruction process, and it is important to discuss all options with the patient to provide optimal results. From the timing of the procedure, to procedure choice and use of chemoradiation, the entire scope of the cancer treatment must be considered before proceeding with reconstruction.
Anatomy and Physiology
The extent of the ablative surgery will, to some extent, dictate the choices available for reconstruction. Loss of breast skin, with or without loss of the nipple, can be accounted for with either autologous tissue reconstruction or tissue expansion. 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
A significant consideration during the planning process is the timing of reconstructive procedures. Both immediate repair or delayed repair are options, and 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 reconstruction during the same surgical session as the cancer resection. This prolongs the time under anesthesia but has the considerable advantage of using a more natural skin envelope for reconstructive options. The skin envelope after skin/nipple-sparing mastectomy can leave the patient with a more natural-appearing breast postoperatively.
Oncologic considerations such as stage and BRCA mutation status play a key role in determining if this is a sound option. Immediate reconstruction is affected by the need for adjuvant therapy, specifically radiation therapy. Having a foreign body in the radiated filed significantly increases wound breakdown and other complications. Patients requiring adjuvant radiation are often best served with autologous tissue reconstruction, whether pedicled or free flap in nature. Delayed reconstruction occurs when a patient has a planned mastectomy, then returns to the operating room at a later date to perform the reconstructive portion of the procedure. This option is available for patients who may not have decided whether they wish to have breast reconstruction, or in patients who 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.
Contraindications to breast reconstruction include the following:
- Severe lung or cardiac disease
- Collagen vascular disease
- Older patient (more than age 65)
- Smoker and unwilling to quit
- Unstable emotional history
- Prior abdominal or thoracic surgery that has interrupted blood supply to potential flaps
- Prior radiation therapy
- Advanced breast cancer
No specialized equipment is required. A standard breast surgery tray and microvascular tray, together with an operating microscope are required. Lighted breast retractors such as the Ferriera, Tebbetts, or other such retractors are very helpful though not essential.
An experienced first-assistant or co-surgeon is very 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/or microsurgery is very desirable.
Tissue Expanders and Implants
Expanders and implants are a common breast restoration option because of the simple nature of the procedure. It adds minimal time to the oncologic procedure and has a shorter recovery period. Another benefit is there is no donor site, so there are no complications from donor-site surgery. There can be significant pain associated with tissue expanders, and there is close follow-up needed. This particular option is a good choice for patients who will not need radiation therapy. It is also a good alternative for thin patients who are undergoing a unilateral mastectomy with little to no ptosis of the remaining breast, as implants decrease the natural fall of the breast. Major disadvantages of this option include implant infection, capsular contracture, and especially, frequent visits for tissue expansion. It is also unwise, though not completely contra-indicated, in the irradiated breast as the radiation causes capsular contractures, infection, and risks skin necrosis. Many different implants 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.
The procedure can be performed as an immediate adjunct after initial mastectomy, using the skin flap left by the breast surgeon. If performed during delayed reconstruction, most surgeons will access the flap through the initial scar. This can also be performed via previous scars, via an inframammary incision, or via circum-areolar 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 re-enforce the soft tissue, particularly to re-enforce the inferior aspect of the breast. After the pocket is created, using careful technique, a tissue expander is inserted and the muscle is reapproximated over this. These expanders have a port that is implanted as to be easily accessible through the skin in order 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 at a later date to exchange the expander for the final implant. During the exchange procedure, issues such as capsular contracture and contralateral asymmetry can be addressed.
The transverse rectus abdominis musculocutaneous (TRAM) flap is an excellent option for healthy candidates who have the anatomy desired for the procedure, and is a workhorse for breast reconstruction. The anatomy includes a sufficient amount of abdominal fat, though not an excessive amount, 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 this would compromise the blood supply to the flap. Cigarette smoking is a relative contraindication to this flap as it compromises the vasculature of the flap, and many plastic surgeons will require patients to refrain from any nicotine-containing products for at least two weeks prior to surgery, thou maybe longer. The body habitus is also of particular importance. This procedure is best for patients with a moderate amount of excess abdominal subcutaneous tissues, though not the obese, which would translate to ideal volumes for breast symmetry. This option has an added bonus of creating a natural fall appearance to the new breast mound and performing a lipectomy of the abdomen at the same time. The drawbacks of this procedure are similar to those in most flaps, and the vasculature of the flap is of vital importance. If the vasculature is compromised, the flap will fail and result in necrosis. Since this is a musculocutaneous flap, there is a defect in the abdominal wall that is at higher risk for hernia formation. Similar postoperative care and positioning is adopted as with an abdominoplasty.
TRAM flaps are classified by the blood supply to the flap. The most conventional of all TRAM flaps 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 simplest of the TRAM flaps 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 out the deep inferior epigastric artery perforator and a small area of muscle leaving a majority 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 as relative "workhorse" flaps in autologous breast reconstruction. They add the benefit of taking little muscle and not violating the rectus fascia respectively. However, the use of these flaps requires specialized training to anastomose these fine vessels, typically performed under a microscope, and adds to operative time, though these procedures are performed safely and routinely at most major breast reconstruction centers.
Latissimus Dorsi Flap
The latissimus dorsi is a broad muscle that extends across a significant portion of the back. This creates a flap with extensive uses. It may be an option for patients who wish to have autologous tissue but are too thin, have previous failed abdominal flaps, or are obese. It may, however, require the use of implants or fat grafting 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 can be used as a free flap. In the modern era of breast reconstruction with the widespread utility of the DIEP flap, this is typically relegated to a secondary option.
Nipple Areolar Complex Reconstruction
Although not necessary, the nipple-areolar complex (NAC) completes the breast reconstruction process and is very important psychologically for breast cancer patients. There are many different techniques used to create a new nipple, but the basis of all techniques is to create projection and/or appearance symmetric 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 often extremely effective, technique to recreate the previous pigmentation of the areola and nipple.
For patients, breast reconstruction surgery can help improve confidence in regards to appearance, restore self-confidence, allow comfort in wearing clothing including swimsuits and bras. It also eliminates the need for uncomfortable prosthetics.
Enhancing Healthcare Team Outcomes
Breast reconstruction is primarily done by the plastic surgeon but in many cases, the follow up is by the primary care proivder, nurse practitioner and internist. These healthcare professionals need to know the different types of breast construction procedures and how to follow the patient for breast cancer screening. Breast reconstruction is only done after the patient has complete the treatment course for breast cancer and is deemed free of the malignancy. Finally, prior to breast reconstruction the primary care givers should encourage the patient to discontinue smoking, so that there are no problems with healing after the surgery. The overall outcomes after breast reconstruction are good.