Breast Reconstruction After Mastectomy: Notes

Intro
Trend toward maximal preservation of breast tissues
- nipple/areolar reconstruction, skin-sparing, partial excisions etc.

Prosthetic Reconstruction
Implants remains the most common method.
High rates of patient satisfaction.

Suitable for:
- women with mild to moderate breast volume
- minimal to moderate ptosis
- early-stage breast cancer.

Unsuitable for:
- prior radiation therapy (compromised vascularity; contraction and infection rates).

Method:
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 mound.
- expansion usually complete before scar forms
2) Implant
- once skin is expanded, and can be contoured and optimized at second stage

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 tissue expander
Can be used with 1 or 2 stage.

Complications of implants
Capsule contraction
Rupture
Implant distortion
Pain
Migration
Gel devices were once thought unsafe but are safe.
Also, implants only last ~10-15y.

Autologous Breast Reconstruction
Flaps;
- 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.

Complications
Donor site infection, weakness, contour abnormality and weakness.

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 much better.
Candidates must have adequate skin and fat at the donor site, and must have a thorough understanding of risks and benefits.

Indications
Patient preference
Complex reconstruction with prosthesis failure
Prior radiation.

Options
- 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 therapeutic mastectomy.
Patient preference, mild to moderate volume, and good health.
Small localized tumours <2.5cm; at least 3m form the NAC, no radiation.
- 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 increased.

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 planning.

Plastic / Reconstruction
Either volume displacement or volume replacement.
- displacement = adjacent tissue rearrangement, mastopexy, reduction mammoplasty
--> adjacent rearrangement is reserved for small excisions
--> reduction mammoplasty a good option for large breasts.
Autologous tissue reconstruction for those with smaller breasts and larger defects
- e.g. lat dorsi miniflap or lateral chest wall perforator flap
--> usually immediate.

Complications
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.