The University of Pennsylvania, Division of Plastic Surgery specializes in breast reconstructive surgery. We believe that restoration of the breast following mastectomy has become an integral part of the holistic treatment of breast cancer. Reconstruction of the breast can happen at the time of mastectomy or at a later date as a separate operation depending on a variety of factors. These may include the women’s wishes, desires and goals, the type and size of tumor, the possible need for post-operative radiation therapy or chemotherapy. These decisions are made by the woman in consultation with her surgeon, oncologist, and plastic surgeon.
The overall goals of breast reconstruction are to create a breast mound, to achieve a normal and symmetric silhouette, to limit patient morbidity, and to avoid the need for an external prosthesis. Breast reconstruction in women who desire more than an external prosthesis can be divided into three broad categories: implants with or without tissue expansion, autologous tissue, and a combination of implants and autologous tissue. Regardless of the type of reconstruction chosen, it typically requires more than one procedure to complete breast reconstruction.
For women who chose implant reconstruction, this typically entails multiple stages. Initially, tissue expanders are placed underneath the muscles of the chest. The patient then undergoes sequential inflations of the expander using saline in an outpatient setting to create a sizable ‘pocket’ for the subsequent implant. Once the appropriate ‘pocket’ has been achieved, the patient returns to the operating room for removal of the tissue expander in exchange for a silicone or saline implant. Both types are available, and to date, no study has documented a cause and effect relationship between silicone or saline implants and systemic illness.
Recently, there has been a movement to reduce the number of procedures needed for implant reconstruction by eliminating the need for tissue expansion. This can be achieved with post-operative, adjustable, saline implants that function as both an expander and implant. Another option utilizes cadaveric, dermal matrix to create a pocket to accommodate a full sized implant at the time of mastectomy. Both of these methods obviate the need for an exchange.
Regardless of whether a tissue expander is used, the principle benefit of using implants for breast reconstruction is in the ease of reconstruction and limiting the surgical site to the chest. Implant reconstruction does, however, have both aesthetic and functional downsides. The implant is typically palpable and often visible through the breast skin, with the degree of palpability and visibility being dependent on the thickness of the mastectomy flaps. An implant reconstruction is also less natural in shape and consistency when compared to a natural breast. Implants also have a risk of infection, the most common perioperative implant related complication.
Capsular contracture is another potential complication in implant reconstruction. As an abnormal immunological response to foreign bodies, this occurs when the capsule which forms around the breast implant tightens and squeezes the implant. It can be painful in rare patients and translates to a firming of the breast and a deformation of the reconstruction. Severe contractures, also known as Baker grade III or IV contractures, occur in a small percentage of patients. Finally, implants will rupture at rates of approximately 1% per year, regardless of whether saline or silicone implants are used. Implants are not lifelong devices, and the patient will likely need one or more procedures to replace the implant over her lifetime.
Autologous Tissue Reconstruction
The alternative to implant reconstruction is reconstruction with autologous tissue. The gold standard in autologous tissue reconstruction remains the tissue of the lower abdomen. This tissue can be transferred as a pedicled flap based on the superior epigastric vessels or as a free flap based on the deep inferior epigastric vessels or superficial inferior epigastric vessels. Pedicled flaps remain connected to their native arterial and venous supply while the tissue is transferred to the new location whereas free flaps are completely disconnected from their original blood supply and a new connection is subsequently performed in the new location.
The tissue from the lower abdomen, which came to be known as the transverse rectus abdominis myocutaneous (TRAM) flap, was originally introduced for breast reconstruction nearly 30 years ago. It was initially described and soon popularized as a pedicled flap based on the superior epigastric artery and vein. The pedicled transverse rectus abdominis myocutaneous flap (pTRAM) remains attached by its superior pedicle and muscle and requires division of the rectus abdominis muscle and corresponding fascia at the pubic symphysis. A subcutaneous path is created connecting the abdominal donor site to the mastectomy defect, and the skin, fat, and muscle is tunneled into the defect to recreate a breast mound. This is the most commonly utilized method of autologous free tissue transfer for breast reconstruction.
Alternatively, the tissue of the lower abdomen can be transferred as a free flap based on the deep inferior epigastric artery and vein, the dominant blood supply of the lower abdomen. In the free transverse rectus abdominis myocutaneous flap (fTRAM), the tissues are isolated on some amount of muscle and varying degrees of rectus fascia and muscle are spared. The blood flow to the tissue is then re-established by suturing the deep inferior epigastric artery and vein to the recipient vessels in the chest. The fTRAM utilizes the main blood supply to the TRAM skin island, which is one of the main advantages of the fTRAM over the pTRAM flap.
Subsequently, the deep inferior epigastric perforator flap, or DIEP, was described. The DIEP flap uses the same skin island as the TRAM flap, but preserves all of the rectus muscle and anterior rectus fascia, potentially reducing the risk for abdominal wall weakness and subsequent hernia formation or lower abdominal bulge. The skin island in the DIEP flap is based on one or more perforating branches off the deep inferior epigastric artery and vein.
More recently, the superficial inferior epigastric artery flap (SIEA) was described as the true abdominoplasty flap for breast reconstruction. It is based on the superficial inferior epigastric vessels which arise from the common femoral vessels and course through the subcutaneous tissues. The harvest of this flap does not violate the anterior abdominal wall fascia or musculature and as a result, patients experience less post-operative pain, quicker recovery and no chance of hernia formation. Unfortunately, clinical experience has shown that the superficial inferior epigastric vessels are either absent or too small to adequately perfuse a free flap transfer of abdominal tissue in the majority of patients. These vessels are only adequate for use in approximately 20-30% of patients and are smaller than the deep inferior epigastric vessel system with less blood volume flow as a result.
The decision regarding which type of abdominal tissue flap to use is multifactorial. Ultimately, the decision should be made balancing an aesthetic breast reconstruction with donor site morbidity. The pTRAM requires division of the majority of the rectus muscle and includes a large portion of anterior rectus fascia. The risks of abdominal wall weakness, bulge, and hernia at the donor site and partial flap loss or fat necrosis in this breast reconstruction are serious. Patients with a history of smoking, obesity, hypertension, COPD, diabetes and previous abdominal surgery are considered high risk for the pTRAM. The fTRAM, DIEP, or SIEA flaps require either very little or no muscle and fascia to be taken from the abdomen, and the DIEP and fTRAM are based off of a more robust blood supply. Functionally, the advantages of the free flap versus the pedicled flap for breast reconstruction are decreased donor site morbidity and the ability to utilize the tissue of the lower abdomen in patients regardless of their comorbidities. Additionally, there are aesthetic advantages to free flap breast reconstruction. There is no violation of the inframammary fold, a natural boundary of the breast and there is more freedom in insetting the flap on the chest as compared to the pedicled flap.
Patients desiring autologous tissue reconstruction from the abdomen must have sufficient lower abdominal tissue available to reconstruct the breast. If such tissue is present, there are very few contraindications which preclude a patient from having this type of reconstruction. The few relative contraindications include previous abdominal surgery such as abdominoplasty or other operations that would compromise circulation to the lower abdominal tissue. More general contraindications of free flap surgery focus on a surgeon’s lack of experience or with an institution’s ability to properly monitor flaps in the postoperative period.
If the lower abdomen is not a sufficient donor site, or if previous surgery eliminates the potential use of this tissue, a number of alternative flaps from other parts of the body have been developed as additional options. The most commonly used of these alternative flaps include the latissimus dorsi flap, the inferior and superior gluteal artery perforator flaps, and the transverse upper gracilis flap. Other less commonly utilized options include free flaps based on tissue from the lateral thigh and on tissue superficial to the iliac crest. These flaps all have potential complications and associated morbidities, however are still sources of autologous tissue for reconstruction.
As in all procedures, there are complications associated with autologous breast reconstruction. The adverse outcomes of autologous tissue reconstruction are total flap failure or partial flap failure. Total flap failure, the most feared complication, typically occurs due to a venous or arterial thrombosis of the vessels supplying the flap. With improved operative technique, this has come to be an uncommon complication. Experienced physicians have loss rates which are less than 1%. If the tissue is taken from the abdomen problems with abdominal weakness, hernia, or bulge may occur. Rates for abdominal weakness and hernia or bulge vary for the different type of flap. Patients may also experience hematomas, seromas and wound healing problems at the donor site or the recipient site.
At the University of Pennsylvania, Division of Plastic Surgery, the plastic surgeons are well trained and perform the most sophisticated types of breast reconstruction on a daily basis. Our goals include providing the patient with the most aesthetic reconstruction while minimizing donor site morbidity. We will discuss your options for breast reconstruction with you and work with your surgical, medical, and radiation oncologists is providing you with the safest and most appropriate surgical plan to restore your body and to help you heal.
Nipple-Areolar Complex Reconstruction
Reconstruction of the nipple-areolar complex is an important component to complete breast reconstruction as the nipple is the central focus when viewing the breast. This has also been shown to have a major psychological benefit to the patient when compared to those without nipple areolar complex reconstruction. Most methods of mastectomy in prophylactic patients remove the nipple-areolar complex along with the breast tissue as the nipple contain extensions of the ductal system that are also at risk for neoplastic disease. The resulting initial post-op reconstruction is therefore left without a nipple. Several months later, the patient may elect to undergo nipple reconstruction with local flaps, grafts, or a combination of the two.
Local flaps are the most common technique, but require adequate soft tissue that is well vascularized and of sufficient thickness. Autologous reconstructions commonly utilize this form of nipple reconstruction. If there is inadequate soft tissue for local flaps, grafts are a useful alternative. The main disadvantage of a graft is that a donor site is potentially required, depending on the graft type. Tattooing of the nipple and areola can later be performed, completing the reconstruction of the nipple-areolar complex. In select patients, tattooing can be utilized as the only form of the reconstruction.
Although most forms of mastectomy remove the nipple-areolar complex, the nipple sparing mastectomy (NSM), removes the breast tissue but spares the nipple and areola. This type of nipple sparing mastectomy obviates the need for nipple-areolar reconstruction and reduces the number of procedures needed to complete the breast reconstruction. The nipple however, will likely remain numb. Studies have shown a wide range of occult nipple involvement in women diagnosed with cancer, depending mostly on the tumor size, location, multicentricity, lymph node involvement, and intraductal component. A discussion with the surgical oncologist will determine whether the patient is a candidate for this type of procedure.
If the patient is not a candidate for a nipple sparing mastectomy, nipple areolar complex reconstruction has been shown to have a positive impact on a patient’s satisfaction with the cosmetic result of the breast reconstruction.
Timing of Breast Reconstruction
The timing of breast reconstruction is another important factor to consider. Breast reconstruction can occur at either the time of mastectomy or at some point after the initial mastectomy is completed. These two time frames are referred to as immediate or delayed reconstruction.
Most surgeons agree that the aesthetic result and technical ease are improved in an immediate breast reconstruction compared to delayed reconstruction. At centers that perform immediate breast reconstructions, the breast oncologic surgeons typically utilize skin sparing mastectomies (SSM). This method of mastectomy allows for satisfactory local control of the breast cancer while preserving the breast boundaries. When breast reconstruction is performed in the immediate setting, there is no scar contracture to overcome and the skin envelope helps maintain the natural borders of the breast. By preserving the natural skin brassiere, the reconstruction is more straightforward and leads to a reconstruction that is more symmetric to the opposite breast.
In delayed reconstruction, the natural borders no longer exist. The plastic surgeon must recreate the mastectomy defect and redefine the borders. The quality of the chest skin must be critically evaluated, as some patients will have had chest wall irradiation in which case the resulting scar and skin contracture may limit the projection and ptosis of the breast pocket. This may lead to difficulty expanding the skin or may require ecruitment of skin for the breast from another part of the body.
Overall, breast reconstruction, either with implants or tissue, has shown to improve the patients’ quality of life by restoring the patients’ sense of self and body image. It does not hinder the treatment of the cancer or hide any recurrences. In fact, breast reconstruction aids in the total recovery of the breast cancer patient through physical and mental rehabilitation.
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