Breast Reconstruction

Published on 11/04/2015 by admin

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Last modified 11/04/2015

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CHAPTER 22 Breast Reconstruction

Suhail K. Kanchwala, Joseph M. Serletti

Case Study

A 38-year-old female undergoes genetic testing after her sister is diagnosed with breast cancer and is found to have a BRCA2 mutation. She is 5 feet 11 inches tall and weighs 120 pounds. She has decided to undergo bilateral prophylactic mastectomy and presents to your office to discuss options for breast reconstruction.

BACKGROUND

Breast reconstruction has become an essential component of the care of women with breast cancer. The goals of modern breast reconstruction are to recreate a natural-appearing breast mound that matches the opposite breast in size, contour, and degree of ptosis (i.e., droopiness). This chapter discusses a variety of alloplastic (implant-based) and autologous techniques for breast reconstruction after mastectomy.

Autologous reconstruction is defined as any form of breast reconstruction that uses a patient’s own tissues to recreate the breast mound. A variety of donor sites can be used for autologous breast reconstruction, including the lower abdomen, buttocks, and back. Alloplastic reconstruction refers to any form of breast reconstruction in which an implant is used. Implant-based reconstruction is typically performed in stages. The first stage involves placement of an inflatable tissue expander that permits the recruitment of additional skin and soft tissue. Subsequently, the expander is replaced with a permanent prosthesis.

Delayed breast reconstruction is defined as reconstruction that occurs after a patient has undergone a mastectomy. Delayed breast reconstruction is most commonly performed for patients who require postoperative radiation therapy. Immediate breast reconstruction, on the other hand, refers to any reconstruction that begins at the time of mastectomy.

Immediate reconstruction is performed at the time of mastectomy. Delayed reconstruction is performed after the mastectomy is completed.

INDICATIONS FOR BREAST RECONSTRUCTION

I. Total Mastectomy Defect: Breast reconstruction most often follows total mastectomy (i.e., removal of the nipple–areolar complex as well as the complete removal of breast tissue) for the treatment of malignancy or a premalignant condition. Genetic screening for mutations within the BRCA gene loci has led to a dramatic rise in the frequency with which bilateral prophylactic mastectomy is performed. Such procedures are often coupled with bilateral reconstruction.
II. Partial Mastectomy Defect: Lumpectomy deformities after “breast-conserving” therapies are sometimes significant enough to justify reconstruction.

PREOPERATIVE EVALUATION

I. History: A number of factors influence the choice of a reconstruction technique. A history of radiation therapy or planned postmastectomy radiation therapy significantly influences the timing and choice of a reconstruction approach. Specifically, implant-based techniques are contraindicated in patients who are likely to receive radiation therapy.

Will your patient require postoperative radiation therapy?

II. Current smoking adversely affects wound healing after surgery for breast reconstruction. Patients should be encouraged to stop smoking several weeks before surgery.
III. The presence of diabetes can have an adverse effect on wound healing. Appropriate perioperative management of blood sugar is essential.
IV. Patient age can influence the choice of reconstructive technique. Elderly patients are at slightly higher risk for complications after autologous reconstruction. Conversely, autologous reconstruction is often favored in younger patients.
V. The lower abdomen is the most common source of autologous tissue for breast reconstruction. Patients must, therefore, have sufficient lower abdominal tissue to allow for autologous reconstruction. Very thin patients are often better served by implant-based reconstruction. Although obese patients have sufficient tissue, they are also at greater risk of developing wound complications.

What is your patient’s body mass index?

COMPONENTS OF THE PROCEDURE AND APPLIED ANATOMY

There are various techniques for reconstructing the breast mound after mastectomy. The most common procedures involve using either autologous tissues (e.g., transverse rectus abdominis myocutaneous [TRAM] flap), tissue expander placement followed by a silicone gel prosthetic implantation, or some combination of the two (e.g., latissimus dorsi flap with implant).

Preoperative Considerations

Autologous reconstruction procedures are typically lengthy and require the placement of a urinary catheter for bladder decompression and monitoring of urine output.

Patient Positioning and Preparation

I. The patient is placed supine on the operating room table. The patient should be placed with the hips at the break in the table to facilitate sitting upright.
II. The sterile preparation is applied to both breasts, the entire abdomen, and the bilateral groin area.

Skin-Sparing Mastectomy

Mastectomy techniques have a significant effect on the outcome of autologous breast reconstruction. Since 1996, the skin-sparing mastectomy has been increasingly used in conjunction with immediate autologous breast reconstruction. A skin-sparing mastectomy is typically performed with a periareolar incision and is so named because the skin envelope of the breast is kept intact during the procedure (Fig. 22-1). Thus, the reconstructive surgeon must simply replace the volume of the mastectomy specimen with either autologous tissue or an implant. This approach avoids the challenges associated with shaping the breast during traditional delayed reconstruction.

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