6.6 Bilateral Breast Reconstruction
Bilateral reconstructive procedures have the advantage that symmetrical breast shape and volume (important to a satisfactory outcome) are more easily achieved than in unilateral reconstruction. The indications for the procedure are based on the same criteria as previously described for the individual procedures.
However, the operation is considerably more elaborate, and the burden on the patient is much greater, particularly in autologous tissue transfer procedures. This is a critical factor in establishing the indication.
The lower abdominal flap is particularly well-suited for bilateral procedures, as it allows the use of two “hemiflaps” to reconstruct both breasts. Normally, breast size is positively correlated with excess lower abdominal tissue, so that there is generally sufficient tissue for bilateral reconstruction.
A disadvantage of this method is the substantially longer operating time. The procedure takes eight to nine (or more) hours, as it can only be performed in one stage.
The indication for this procedure therefore needs to be considered extremely carefully. The patient also has to be prepared for what is perhaps the most complex operation in the field of breast surgery.
This results in particular from the fact that the bilateral pedicled TRAM flap procedure should no longer be carried out, due to the unacceptable degree of weakness in the abdominal wall.
Ideally, two perforator flaps would be used. However, as this requires two surgical teams in order to reduce the operating time and these ideal conditions are not always available, options include combining two free TRAM flaps or a free TRAM flap with a perforator flap, or a unipedicled rectus flap with a contralateral perforator flap.
The respective surgical techniques have been described in the previous sections above. The difference here is of course that two separate flaps are created, with the lower abdominal skin flap being transected along the midline.
Dissection of a perforator hemiflap requires specialized surgical experience, as it eliminates the option of using the contra-lateral side as a fall-back.
For closure of the abdominal fascia in bilateral free TRAM flaps, or in combination procedures with a pedicled and a free TRAM flap, an onlay or inlay Prolene mesh always has to be used to strengthen the abdominal wall. Relief of stress on the abdominal wall is always indicated for 3 months following bilateral procedures.
Despite the considerable amount of time and effort involved, bilateral breast reconstruction with a lower abdominal flap is particularly rewarding for both the patient and the surgeon.
Bilateral reconstructions are, of course, possible with all of the other reconstructive procedures that have been described. In contrast to the lower abdominal flap, it is possible to carry these out in two stages. A two-stage surgical procedure is especially recommended for SGAP flaps.
In addition to its use after cancer surgery, bilateral reconstruction with autologous tissue has also proved to be a viable option in patients with extensive capsular contracture after prophylactic mastectomy with implant reconstruction.
From the patient’s point of view, bilateral implant reconstruction is the least demanding procedure. Given similar anatomical conditions, it is relatively easy to achieve a symmetrical shape and volume with implants and thus aesthetically pleasing results ( Fig. 6.9 ).