This chapter covers the sensitive area of breast reconstruction following mastectomy. Every consideration to be addressed during patient presentation is listed, and treatment options are detailed. These include reconstruction with tissue expander, utilizing implants, the use of autologous tissue and an underlying expander, delayed reconstruction, and reconstruction with autologous tissue alone. Helpful tables identify the ideal candidates for each treatment option, and actual surgical procedures for each treatment option are thoroughly covered. The chapter concludes with suggestions for postoperative care and some paragraphs on possible complications (skin necrosis, seroma, infection).
33 Breast Reconstruction with Devices
33.1 Goals and Objectives
Understand the proper evaluation of prospective breast reconstruction patients.
Clearly define the indications for the various methods of reconstruction, and which patients are most appropriate for each modality.
Understand the steps involved in reconstruction, and the anatomic considerations affecting each step.
Understand appropriate perioperative care to maximize patient safety and quality outcomes.
33.2 Patient Presentation
Patients presenting for breast reconstruction will fall into one of two categories: those desiring immediate reconstruction at the time of mastectomy or those requiring a delayed reconstruction. Some patients will need reconstruction of both breasts, and for others the surgeon must try to match the native breast after a unilateral mastectomy.
With the advent of genetic testing, plastic surgeons are seeing a greater number of women desiring prophylactic mastectomy. In general, these patients are younger, healthier, and will not have the concerns arising from adjuvant chemotherapy or radiation.
The initial history should include information about the patient’s oncologic status, including planned or on-going chemotherapy, and previous or planned radiation. For patients having immediate reconstruction, the need for radiation therapy may not be well defined at the time of surgery, and will depend on ultimate node status and pathologic examination of the surgical specimen. Additional history should include other surgeries on the breasts, such as previous biopsy or cosmetic procedures, and assessment of co-morbidities, especially cardiac or other major system disease, diabetes, and the use of anticoagulants or anti-platelet agents.
Physical assessment includes evaluation of (1) the diameter and shape of the patient’s breast (or previous breast boundaries, if postmastectomy) which will predicate the base diameter of the tissue expander or implant; (2) skin quality, including the presence of stretch marks, amount of subcutaneous fat, and previous surgical scars; (3) skin laxity, including assessment of fibrosis from previous surgery or radiation therapy; (4) thickness and breadth of the underlying pectoralis muscle. The presence of previous scars, either from breast biopsies/lumpectomies, or from breast contouring (i.e., mastopexy), can affect the underlying blood supply, and hence reliability of the skin flaps. Examination should be done in both the supine and sitting positions, to assess the mobility of the skin, areas of redundancy, and thickness of the subcutaneous fat, which in delayed reconstruction, is not always uniform. The hands-on-hips position is beneficial to assess skin redundancy in the lateral chest, variously known as the lateral thoracic fold or lateral chest roll.
Previous radiation therapy does not preclude the use of an expander, but such patients should be approached on a case by case basis, and apprised of the greater risk of complications and implant loss. 1 , 2 Patients vary in their response to radiation, and the tissue quality should be carefully assessed. If the skin is noticeably tighter and thinner than the un-radiated side, then consider autologous tissue, either as the sole reconstructive technique, or to overlay the expander. If the skin is mobile and appears healthy, and the muscle is pliable and of good caliber, then muscle fibrosis is usually minimal, and subpectoral expander placement may be considered. The patient should be advised that autologous tissue could be needed as a secondary procedure if complications are encountered, or if the tissue will not expand sufficiently (Fig. 33‑1, Fig. 33‑2, Fig. 33‑3).
33.3 Preparation for Surgery
Diagnostic data required in preparation for surgery is similar to other elective major procedures and is dependent on age, the presence of comorbidities, and requirements of the surgical center in which the procedure will be performed. In general, the author requires a baseline hemoglobin and hematocrit, and basic chemistry on most patients. Diabetic patients should have good glucose control, and a hemoglobin A1c within normal range. Patients who have recently undergone chemotherapy should have a total neutrophil count (TNC) > 1,500. Cardiac workup is dependent on patient age, history and the facility in which the procedure is being done. In general, if an electrocardiogram is abnormal, internal medicine or cardiology evaluation should be obtained. Consider nasal MRSA screening, or empiric decolonization with mupirocin. 3 The patient is asked to bathe daily with a chlorhexidine solution, and to use chlorhexidine mouthwash, beginning five days prior to surgery.
Treatment Options and Indications:
The choices for surgical treatment fall into two categories, immediate or delayed reconstruction:
Immediate reconstruction with tissue expander. If the surgeon performing the mastectomy usually leaves healthy, well-vascularized skin flaps, then immediate placement of a tissue expander is performed (Table 33‑1).
Immediate, direct to implant reconstruction. If the skin flaps appear reliable, and the patient desires the same or smaller breast size, it may be feasible to place the permanent implant at the time of the mastectomy (Table 33‑2).
Immediate reconstruction with autologous tissue and underlying expander. In a patient with less optimal tissue quality, especially if previously irradiated, a latissimus flap will provide additional skin envelope, and a healthy, well vascularized layer over the expander (Table 33‑3).
Delayed reconstruction. If the patient’s health is not optimal or if the skin flaps after mastectomy are of questionable viability, then it is in the patient’s interest to defer the reconstruction to a later date. In the case of a planned immediate reconstruction, but poor quality skin flaps, proceed to verify hemostasis, use appropriate antisepsis, and close the wound gently over a drain. The subsequent loss of a portion of the skin envelope will not jeopardize an underlying device, and chemotherapy will not be delayed for treatment of a device infection. Some surgeons may proceed after objective assessment of the skin flap blood supply via fluorescence or intraoperative angiography, with appropriate resection of compromised skin. The author does not favor this approach, since it does not fully remove the risk of poor healing and subsequent loss of the device and delays in adjuvant therapy (Table 33‑4).
Immediate or delayed reconstruction with autologous tissue alone. Patients with appropriate body habitus, or a reluctance to use implants, may be reconstructed with either pedicled or free tissue transfer.
33.5 Surgical Preparation
Most patients undergoing mastectomy and immediate reconstruction will stay one night in hospital. The occasional stoic, small breasted, unilateral patient may choose surgery on an outpatient basis. Effective control of postoperative nausea is beneficial, as the straining associated with retching may tear freshly repaired tissue, and increase the risk of postoperative bleeding. Preoperative medications such as ondansetron (Zofran) and aprepitant (Emend) have proven efficacy, as does transdermal scopolamine. Continuous mechanical intraoperative DVT prevention via sequential compression boots is mandated in all breast reconstruction surgeries done under general anesthesia. A DVT risk assessment should be completed preoperatively, and chemoprophylaxis should be used if indicated. The longer operative times associated with more complicated reconstructions will skew the analysis toward adding chemoprophylaxis.
Preoperative marking may be done in either the sitting or the standing position. The author marks the midline and inframammary fold, and also the lateral extent of the breast, provided it is well defined. For immediate reconstruction, the mastectomy surgeon may be willing to place these marks preoperatively. Some surgeons will efface the inframammary fold during the mastectomy, so preoperative marking is beneficial.
For immediate reconstruction, it is the author’s practice to have the mastectomy surgeon verify hemostasis, close the wound loosely with staples, and then apply a Tegaderm or OpSite dressing (Fig. 33‑4a). The patient is then sterilely re-prepped and re-draped, and new instruments are used for the reconstruction. Antibiotics may be redosed, depending on time interval since the initial dose. In a unilateral reconstruction, it is helpful to prep the uninvolved breast into the field, to allow better assessment of symmetry. Covering the exposed nipple with a Tegaderm will isolate bacteria residing in the milk ducts.
33.6 Operative Technique—Expander
33.6.1 Immediate Reconstruction with Tissue Expander
In a bilateral reconstruction, the author prefers to begin on the breast cancer side. If the tissue quality differs appreciably between sides, it will more likely be impaired on the side where the cancer resection was performed. This allows the surgeon to judge the most appropriate tissue expander or implant, and to determine the need for allograft or autologous tissue. Both sides can be approached simultaneously, alternating from side to side, however this adds operative time, and with experience becomes less useful. Cover the opposite nipple with Tegaderm in unilateral reconstruction.
The mastectomy wound should be irrigated clean, if needed, and reverified for hemostasis. Bleeding points are often present on the deep surface of the skin flaps, and these should be controlled completely but carefully. Infiltration of local anesthetic is then performed to help with postoperative pain relief. The author injects the medial pectoralis, the serratus along the mid-axillary line, and the body of the pectoral muscle, which helps to decrease postoperative muscle spasm (Fig. 33‑4, Fig. 33‑5).
Assess the skin flaps for quality and vascularity. If the skin flaps are not adequate in extent or in perfusion, then the reconstructive surgeon may simply close the wound over a drain, and perform the reconstruction in a delayed fashion. Keep in mind that the ultimate objective is a satisfied patient, with a durable, healthy reconstruction. It is worth an extra surgery to obtain this goal, if the skin coverage is not adequate for an immediate procedure.
If the inframammary fold (IMF) has been effaced, it should be reattached for better postoperative definition. Use the minimum number of sutures necessary, to avoid impairing perfusion in the inferior skin flap. At this point, a preliminary decision is made regarding the need for acellular dermal matrix (ADM) or absorbable mesh. 6 If the pectoralis major muscle is of good caliber, extends to the inframammary fold, and there is adequate soft tissue in the serratus and its overlying tissue, then total muscle coverage is performed (Fig. 33‑4b, Fig. 33‑5). There is published clinical data supporting a slight decrease in infection risk with total sub-muscular placement, as compared to ADM (Fig. 33‑6). 3
The pectoral muscle is elevated, using a lighted retractor for visualization. If the inferior border of the pectoralis is high relative to the IMF, then ADM or absorbable mesh is used to hold the muscle out to length (Fig. 33‑6). If the inferior border of the muscle is at or below the IMF, then the muscle is left attached to the overlying skin flap, but is released from its origin on the ribs, to facilitate better expansion of the lower pole. If the serratus is to be elevated, this is done from medial to lateral, dissecting far enough to accommodate the footprint of the desired expander. Perforating vessels from the intercostal arteries can produce troublesome bleeding, and should be carefully controlled. Transection of nerve branches is avoided if possible. The author washes the wound clean at this point, first with chlorhexidine irrigation (Irrisept), and then with triple antibiotic solution.
A variety of expanders are available, with most surgeons choosing a device with an integrated port. Suture tabs, combined with the textured surface of the device, will help prevent rotation of the expander during the period of inflation. The expander is brought onto the field, and checked for leaks. Many surgeons change gloves before handling the expander (or implant), and it is good practice to minimize the number of other scrubbed team members who touch the device. Aspiration of most of the air from the expander will facilitate insertion. The device is checked for correct orientation, and secured with at least one suture tab. Expanders may have a tendency to migrate laterally during inflation, and this can be limited if a medial suture tab is well secured to the underlying tissue.
The device is rinsed with antiseptic or antibiotic after insertion, and if the serratus is utilized, it is sutured to the lateral pectoral edge with horizontal mattress sutures of 2–0 Vicryl. ADM or absorbable mesh may be inset at this point along the inferolateral border of the expander. Port position is verified with the supplied magnet, and an initial saline fill is performed. Consider the quality of the skin flaps when deciding the amount of initial fill volume, as undue tension will impair circulation in the skin.
If the lateral thoracic skin has been detached from the chest wall over a wide area, it is beneficial to redrape this against the underlying serratus, and secure with several sutures. At this level, the long thoracic nerve has usually arborized so that it is not at risk. If the sutures are tied loosely there is less likely to be visible skin puckering postoperatively.
In immediate reconstruction, at least one closed suction drain is utilized. In patients undergoing axillary node dissection, a second drain is often placed to drain the axilla. In selected patients having delayed reconstruction, the drain may be omitted if the wound is quite dry, and there is not a large amount of free space that would benefit from suction coaptation. Tunneling the drain through 3 to 4 cm of subcutaneous fat before exiting the skin may decrease the risk of bacterial contamination ascending along the drain tract. The drain is secured to the skin with a double suture of 2–0 silk.
The skin flaps are then redraped, and a final assessment made of skin viability. Any questionable areas should be excised to good dermal bleeding. Significant dog-earing is also contoured at this time. Tissue approximation is done in layers with absorbable tissue. Several tacking sutures to the outer surface of the pectoralis are useful to stabilize the closure, decrease shearing, and lower the risk of seroma. The author uses 2–0 Vicryl in the subcutaneous fat, 3–0 Vicryl in the deep dermis, and subcuticular 4–0 Monocryl in the skin. After skin closure, the incision and drain exit sites are painted with either betadine or chlorhexidine. The author injects 20 mL of 0.25% bupivacaine through the drain tube after skin closure. The suction bulbs are attached, but not placed to suction until the recovery room, allowing time for topical action of the bupivacaine.
Some surgeons prefer a bulky gauze dressing, however it is the author’s practice to use Tegaderm or Opsite on the incisions, with an Ace wrap or surgical bra placed directly over the transparent dressing. If an Ace wrap is used, it will need to be re-wrapped at least once daily, and this provides an opportunity for the patient or family member to examine the wound, and report any erythema or other concerns. The Ace wrap should be wrapped comfortably snug, but not tight, sufficient to decrease motion of the expander, and hence postoperative pain, and decrease the risk of venous bleeding. Tight external wrapping could adversely affect skin flap vascularity. The urinary catheter is removed before awakening, to encourage postoperative ambulation.