Breast Reconstruction After Mastectomy: Notes
Trend toward maximal preservation of breast tissues
- nipple/areolar reconstruction, skin-sparing, partial excisions
Implants remains the most common method.
High rates of patient satisfaction.
- women with mild to moderate breast volume
- minimal to moderate ptosis
- early-stage breast cancer.
- prior radiation therapy (compromised vascularity; contraction and
Traditionally a two-stage procedure:
1) Tissue expander.
- textured and contoured saline device (not gel)
- safe and efficacious
- placed in the total or partial subpectoral position.
- then filled to 40-70% capacity in the operating room.
- psychological benefit to women waking up to some degree of breast
- expansion usually complete before scar forms
- once skin is expanded, and can be contoured and optimized at
Alternative method is the single-stage
- must be ample breast skin available; e.g. after skin sparing
mastectomy or with nipple / areolar preservation.
--> permanent implant placed immediately.
--> most appealing to women considering prophylactic mastectomy.
Risk is that thin skin flaps can necrose or distort.
--> revision rates have approached 20%
Accellular Dermal Matrices
Since 2005; derived from human or animal sources
Allow total revascularization and fibroblast ingrowth
Benefit is to extend the pectoralis major and compartmentalize the
Can be used with 1 or 2 stage.
Complications of implants
Gel devices were once thought unsafe but are safe.
Also, implants only last ~10-15y.
Autologous Breast Reconstruction
- most commonly TRAM (transverse rectus abdominis musculocutaneous)
- and lat dorsi flaps.
Both can create a very nice breast mound
- but require morbid harvest of donor site muscle
--> really want the blood supply to the adipocutaneous component
rather than the muscle itself.
These last forever and improve with time, unlike prostheses.
Donor site infection, weakness, contour abnormality and
Hence, other options developed.
Free tissue transfer
Amount of muscle harvested minimized or eliminated.
- can be taken from abdomen, flanks, gluteal region, medial thight,
and posterior thorax.
- two types of flaps are musculocutaneous and perforator.
--> musculocutaneous are muscle-sparing
--> perforator require no muscle at all.
Donor site morbitidy better and hernia and contour abnormalities
Candidates must have adequate skin and fat at the donor site, and
must have a thorough understanding of risks and benefits.
Complex reconstruction with prosthesis failure
- muscle-sparing TRAM
- deep inferior epigastric artery perforator flap (DIEP)
- superior glutealartery perforator (SGAP)
--> DIEP best as uses adiopcutaneous tissue of lower abdo without
sacrificing the rectus.
Need a dominant perforator artery and vein to perfuse the flap.
SGAP used when inadequate tissue at abdo wall.
- more complex; smaller vessels.
Reconstruction with nipple/areolar preservation.
Safe in selected women
- mild to moderate breast volume (A-B cup) having prophylactic or
Patient preference, mild to moderate volume, and good health.
Small localized tumours <2.5cm; at least 3m form the NAC, no
- if big breasts, poor blood supply left to NAC.
Generally done via an infra-areolar incision with lateral extension.
- vascularity of flap optimal, and breast borders easily defined to
achieve adequate exposure.
Reconstructive options include prostehtic devices or flaps.
- patient, disease, surgeon factors.
Important to maintain symmetry.
Incidence of local recurrence is usually <5% when done properly.
Oncoplastic Breast Surgery
Partial mastectomy with wide margins and partial reconstruction.
Oncologic = wider margins of resection.
- reduced local recurrence; approaches that of mastectomy.
Women usually able to reserve the NAC and patient satisfaction
Factors to consider
1. Oncologic feasibility.
- tumours <5cm when breast volume is large
- women with smaller tumours if smaller breast volume
- stage I and II disease only (or down-staged neoadjuvant disease)
2. Need to carefully image the breast to determine location and
orientation of cancer
- anticipate the extent of skin and parencymal defects to facilitate
Plastic / Reconstruction
Either volume displacement or volume replacement.
- displacement = adjacent tissue rearrangement, mastopexy, reduction
--> adjacent rearrangement is reserved for small excisions
--> reduction mammoplasty a good option for large breasts.
Autologous tissue reconstruction for those with smaller breasts and
- e.g. lat dorsi miniflap or lateral chest wall perforator flap
--> usually immediate.
Principle caveat is to get good margins.
- cavity sampling recommended; clips placed to enable re-excision.
... if margins positive may need to re-excise or go to mastectomy.
Delayed healing, seroma, hematoma, asymmetry
Nipple necrosis or loss of sensitvitiy.
But overall, vs skin-sparing mastectomy, improve breast and nipple
sensation and better functional outcome.