Case 34 Breast Cancer Reconstruction
34.1 Description
A 55-year-old female with evidence of left-sided breast biopsy and large C-cup breasts
Image shows breast asymmetry with the left side higher than the right, suggestive of possible previous procedure versus baseline asymmetry
Notable laxity of the lower abdomen; reasonable candidate for autologous reconstruction
34.2 Work-Up
34.2.1 History
Breast cancer diagnosis: Ductal carcinoma, lobular carcinoma, and inflammatory breast carcinoma are most common
Noninvasive versus invasive
Location, tumor size, node, and metastasis (TNM) classification, and contralateral disease
Previous procedures or surgeries: Oncologic or aesthetic breast procedures, history of surgery, or radiation elsewhere in the body
Breast screening and diagnostic testing: Mammography, ultrasound, magnetic resonance imaging (MRI), computed tomography (CT) scan, pathology, and molecular and genetic testing
Age, pre- versus post-menopausal, pregnancy plans, and breastfeeding
Family history of breast and other cancers
History of smoking/tobacco use and comorbid conditions
Patient’s reconstructive desires, expectations, and desired timing
34.2.2 Physical Examination
Body habitus and body mass index (BMI): Weight (kg)/Height (m2)
Current breast characteristics (including contralateral breast)
Measurements (see Fig. 36.2, Table 36.2)
Breast masses and presence of lymphadenopathy
Quality and quantity of skin; presence and location of scars and deformities
Donor site availability and presence of scars: Abdomen, back, buttocks, and thighs
Lymphedema
34.2.3 Pertinent Imaging or Diagnostic Studies
Mammogram or other diagnostic imaging (especially if operating on unaffected breast)
Consider CT or MR angiography, if planning autologous free flap
34.3 Consultations
Surgical (breast) oncology, medical oncology, and radiation oncology (if needed)
Tumor board
34.4 Patient Counseling
Overall, 89.7% 5-year survival rate; 98.7% 5-year survival for localized breast cancer
BRCA mutations: Lifetime risk >50%, with increased risk of contralateral disease
Breast reconstruction often requires multiple operations
34.5 Treatment
The most important consideration is oncologic safety and prevention of recurrence
Surgery, chemotherapy, and radiation are mainstays of treatment
34.5.1 Preoperative and Surgical Considerations
Planned lumpectomy versus mastectomy
Immediate reconstruction: Psychosocial benefit, with reduced number of operations
Delayed reconstruction
Overall lower rate of complications
Preferred if medical comorbidities are significant, tissue quality is poor, oncologic safety of primary procedure is not certain, reconstruction risks are delaying adjuvant therapies, patient is not ready to make an informed decision, or breasts are large and ptotic
No reconstruction at all remains an option for treatment, especially in very sick patients
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