Breast Reconstruction

Breast reconstruction following total mastectomy has benefits in body image, self-esteem, sexuality, and quality of life. Most of the women, especially younger patients, decide on breast reconstruction procedures after mastectomy. Because detection of BRCA-1/-2 gene mutations has become a more standard test, prophylactic mastectomy in affected women is increasing with understandably high demands for the aesthetic outcome.

Breast reconstruction depends on different conditions and should always be attempted in a multidisciplinary approach. First, an optimal oncologic and surgical treatment decision must be made. Advantages and disadvantages concerning oncologic safety and aesthetic outcome should be considered and discussed extensively with the patient before choosing a surgical procedure, which could be either breast-conserving therapy (BCT), mastectomy, or skin- or nipple-sparing mastectomy (SSM/NSM), respectively. In addition, possibly indicated preoperative or postoperative radiation therapy and desired technique of breast reconstruction should be considered before starting the oncologic surgery.

Breast reconstruction may be classified in mainly 2 different considerations, the reconstruction type (alloplastic vs autologous) and the timing of reconstruction (immediate vs delayed).

Implant-based Breast Reconstruction

Although autologous breast reconstruction is offered to women as a reconstructive option, implant-based reconstruction appears to be the most common type of breast reconstruction, reaching 80% of any reconstruction in most centers. A 10-year data analysis from the United States indicates that between 1998 and 2008 immediate implant-based breast reconstruction increased on average 11% per year, whereas autologous reconstruction remained stable. The increasing number of prophylactic bilateral mastectomies in the United States is probably one reason for the increased use of implants for immediate breast reconstruction (IBR). This trend may be due to the health system and cost coverage allowing CPM and IBR. In contrast to the findings in the United States, Canadian data from a comparable time period showed a constant number of contralateral prophylactic mastectomies over time.

Nevertheless, implant-based breast reconstruction has many advantages: short operation time, presumably easy method, low early postoperative complication rate, and short hospital stay, resulting in low treatment costs. However, long-term complication rate is high; more than 30% of women who receive implants after mastectomy present complications during the first 5 years after surgery. The most frequent problems are capsular contracture, followed by implant rupture, hematoma, and wound infection. Complications among women with cosmetic implants are much lower (12% after 5 years). Irradiation of the breast significantly leads to an even higher risk of early capsular contracture and other complications after prosthetic breast reconstruction. Because invasiveness of surgical treatment of breast cancer has decreased over time, adjuvant radiation therapy increased. Therefore, the number of irradiated patients desiring breast reconstruction is constantly growing, and the reconstructive surgeon must consider this problem with his surgical treatment.

Autologous Breast Reconstruction

In 1982, Hartrampf and colleagues described the use of the superior pedicled rectus abdominis muscle flap with a transverse oriented adipocutaneous skin island (TRAM flap) supplied by the deep superior epigastric artery for anatomically reconstruction of the breast in one single stage without using implants. Since then, this flap was the gold standard for autologous breast reconstruction and is still often used in hospitals where microsurgical expertise is not available. In 1984, Taylor and colleagues and Boyd and colleagues demonstrated the predominance of the inferior epigastric vessels in the blood supply of the TRAM flap, which delivered two to three periumbilical perforators to the skin. Friedman and colleagues described that the critical zones 3 and 4 are usually sufficiently perfused with the inferior pedicled TRAM flap. However, only a few years later, after several refinements of the method, the free deep inferior epigastric perforator (DIEP) flap was first described in 1989 by Koshima and Soeda and has evolved into the workhorse for autologous breast reconstruction currently. This perforator-based free flap, named after the blood vessel providing flow to the flap, deep inferior epigastric artery perforator, significantly reduced the main disadvantage of the TRAM flap, consisting of abdominal wall weakness, including herniation due to sacrifice of the rectus abdominis muscle and large part of its anterior fascia.

Patients may decide against autologous reconstruction because of additional scars from flap harvesting and the complex surgery with longer recovery times compared with prosthetic reconstruction. Other than patient wishes, physical limitations play an important role in decision making. First, enough tissue should be present, and previous surgery must be considered when choosing the preferred donor site. In addition, patient age, medical history (eg, diabetes, arteriosclerosis, coagulopathies), and personal habits (obesity, smoking, alcohol, drugs) may influence the outcome of autologous breast reconstruction.

Immediate Breast Reconstruction

For women affected by breast cancer or with the need for prophylactic mastectomy, IBR has many advantages. It is associated with a reduced recovery time, a better aesthetic outcome, an improved quality of life, and finally, lower surgery- and recovery-related costs. In addition to avoidance of further operations, psychosocial integrity is promoted, because women do not have to live with a missing or unfinished breast, even if only temporarily. Interestingly, however, only 33% of women who are candidates for IBR choose this option.

SSM with IBR is increasingly performed in women with invasive breast cancer, but adjuvant chemotherapy and radiation may increase the rate of complications. The technique of NSM and IBR is an oncologically safe procedure, associated with excellent aesthetic results in therapeutic as well as prophylactic mastectomies, if the postoperative course is without complications. Nevertheless, it has to be mentioned that perfusion of the skin and the nipple areola complex (NAC) can be compromised and lead to necrosis, which can only be compensated by autologous tissue.

The need of radiation after IBR with implants leads to higher rates of capsular contraction, reoperations, wound-healing problems, and implant loss. In autologous breast reconstruction, radiotherapy may compromise the final result of the reconstructed breast because of flap shrinkage or inconvenient scar formation. Therefore, many surgeons may tend to a delayed breast reconstruction (DBR) when using free flaps in cases of an invasive tumor requiring adjuvant radiotherapy. In order not to lose the skin envelope after SSM, one can place a spacer until completion of adjuvant therapy.

Delayed Breast Reconstruction

DBR is defined as reconstructive surgery at any time after mastectomy except immediately. However, is there a need for DBR? Most women who decide for DBR do not undergo reconstructive surgery within the first year after mastectomy. One reason may be that patients have no capacity for thoughts on reconstruction, because they are engaged in processing their underlying disease during the acute phase of breast cancer treatment. Oncologists and surgeons also discourage early breast reconstruction, because most recurrences are seen during the first two years after breast cancer treatment.

Women who are experiencing higher levels of distress, anxiety, and body concerns both before and after mastectomy appear to be significantly likely to select DBR. Also, DBR has the advantage of correcting tissue damage due to radiation or wound-healing complications after mastectomy.

Delayed reconstruction often requires resection of irradiated and scarred skin between the mastectomy scar and the inframammary fold with subsequent need for a larger flap volume. Delayed reconstruction following radiation will typically require autologous tissue in order to achieve an acceptable result.

Finally, if a previously unexpected radiation or chemotherapy will be necessary after mastectomy, complications through IBR can delay the required treatment.