Breast reconstruction options following mastectomy

Advantages of implant reconstruction

Although nonautologous implant-based reconstruction can have some limitations, this procedure attracts many patients as a result of its advantages and good aesthetic results. The mastectomy procedure is prolonged by only about 1 hour, and most patients require only an overnight stay after the procedure. The recovery period is approximately 2 to 3 weeks, at which point tissue expansion is started.

What if radiation therapy is needed?

When treatment of the breast cancer is expected to involve radiation therapy right from the beginning, implant-based reconstruction is not an optimal choice. Radiation can affect the reconstruction in several negative ways. By design, radiation treats cancer by destroying dividing cells. Dividing cells are also required for wound healing and tissue remodeling. Without this remodeling ability, surgical scars are more susceptible to breakdown, which leads to tissue loss. In addition, because the effects of radiation are long-term, over time the thin tissue over the implant might respond poorly to the excessive stress of the implant, raising the possibility that tissue thinning could eventually lead to implant loss.⁷

Certainly there are instances when radiation therapy is not anticipated prior to the extirpative operation but then becomes necessary to complete the cancer treatment, based on final pathology results. Some patients in these circumstances may have had implants placed prior to the decision to give radiation. This does not doom the implant reconstruction to failure, however. Depending on the effect of the radiation and the patient’s body, there might be only a limited impact on the implant and the overall reconstruction result. We recommended close follow-up in these patients to monitor for any long-term complications such as skin discoloration, implant extrusion, or capsular contracture, which can be addressed as they arise.

AUTOLOGOUS RECONSTRUCTION

Techniques using abdominal tissue

As noted above, autologous breast reconstruction uses the patient’s own tissue. If the patient has adequate abdominal fat, the skin and fatty tissue of the lower abdomen may be used to reconstruct the missing breast. Historically, this type of reconstruction has included a portion of the abdominal muscles.

TRAM flap technique. The transverse rectus abdominis muscle (TRAM) flap technique takes advantage of the blood supply within the rectus abdominis muscle and its overlying skin and soft tissue. The muscle serves as the conduit for the blood supply of the skin and fatty tissue used in this method of reconstruction. The distal insertion of the muscle close to the pubic symphysis is cut, and the tissue receives its blood via the superior epigastric artery, which passes through the rectus muscle. This skin and soft tissue is then brought into the defect on the chest beneath the skin by tunneling it through the undermined skin flap between the abdomen and chest.

While the reconstructive results with the TRAM flap are good, this technique has been associated with increased risk of hernias or bulges in the abdominal wall. In sacrificing the rectus abdominis muscle, one of the major contributors to posture and the dynamic abdominal contour of the ventral abdomen is lost and the abdominal wall is weakened. This risk becomes even more significant when both rectus abdominis muscles are used to reconstruct both breasts.

Limitations of techniques using abdominal tissue. Although autologous reconstruction is most commonly performed using tissue from the lower abdomen, flaps from the lower abdomen can be used only when there is sufficient fatty tissue to provide bulk for reconstructing the breast. In thin patients, using flaps from the abdomen may not be a good option. Contraindications to autologous reconstruction using the abdomen include previous abdominal surgery such as abdominoplasty, liposuction, open cholecystectomy, or other major abdominal operations that would compromise circulation to the skin and tissue over the flap. Other relative contraindications to autologous tissue reconstruction using the abdomen are obesity, smoking, a history of blood clots, and other major systemic medical conditions.

Options when abdominal tissue cannot be used

For patients who have insufficient tissue on the abdomen or have had previous abdominal surgery that compromises perfusion to the abdominal tissue, other options for autologous breast reconstruction are available. The gluteal tissue can be used, based on its superior or inferior blood supply, known as the superior gluteal artery perforator (SGAP) flap or the inferior gluteal artery perforator (IGAP) flap. Like the DIEP free flap technique, reconstruction using these flaps also requires a microsurgical procedure.

Another common option involves using skin and muscle from the back, or the latissimus dorsi myocutaneous flap. This flap does not require microsurgery; however, often the amount of tissue available to reconstruct the breast is inadequate to create a breast mound, requiring that the reconstruction be supplemented with an implant beneath the flap.⁸

Pros and cons of autologous reconstruction

Unlike implant-based reconstruction, autologous reconstruction obviously eliminates the need for implant replacement in the future. It also generally results in a more natural-feeling and natural-looking breast. Another advantage is that the breast reconstructed with autologous tissue will grow and decrease in size with weight fluctuations, just as a nonreconstructed breast would. Finally, in many cases the patient also essentially undergoes an abdominoplasty, or “tummy tuck” procedure, by virtue of how the tissue is harvested for reconstruction, which is likely to be welcomed by many patients.