Breast reconstruction

Dispelling false beliefs.

An unfortunate number of patient and health care provider beliefs around breast reconstruction are outdated and false. Patients often think they are too old,¹¹ feel vanity in their desire to undergo reconstruction, worry that reconstruction will interfere with cancer treatment, or believe that breast reconstruction is dangerous and fraught with complications.

The reality is that there are no absolute contraindications to breast reconstruction. Certainly, the patients’ general health and the type and grade of malignancy must be considered. Certain factors such as morbid obesity and smoking considerably limit options. In most cases, however, health- and tumour-related factors will influence the type and timing of reconstruction but not whether or not reconstruction is an option. Breast reconstruction itself does not lead to an increase in recurrence nor increased difficulty in surveillance.

Timing of breast reconstruction.

Immediate breast reconstruction, performed during the same procedure as oncologic resection, has the distinct advantages of decreasing the total number of surgeries, providing improved psychological benefit, and preserving much of the native breast skin and potentially the nipple. Delayed reconstruction might be recommended for patients with advanced disease, those for whom there are uncertainties about disease control, or those not interested in or prepared to make a reconstructive decision at the time of their oncologic procedure (Table 1).

Mastectomy incisions.

Before deciding on a reconstructive technique, a decision about which type of mastectomy is appropriate is made by the general surgeon, if possible in consultation with the plastic surgeon. When immediate reconstruction is not planned, a horizontal incision is made to remove excess skin with the mastectomy specimen and allow the remaining skin to close neatly, flat against the chest wall. When immediate reconstruction is planned, the incision is modified to preserve as much breast skin as possible. Traditionally, “skin-sparing” mastectomy involves nipple and areolar excision as an ellipse, leaving a horizontal scar and most native breast skin behind. Today, in appropriate patients, a “nipple-sparing” approach can be used. In these cases, surgeons will decide where to make the access incision for removal of the underlying breast tissue while preserving all overlying skin, nipple, and areola. A nipple-sparing approach can often be considered if these criteria are met:

• the tumour does not involve the area around the nipple;

• the patient has small- or medium-sized breasts (generally, A to a small C cup size); and

• the patient has good native nipple position (minimal ptosis).

The various incisions types are shown in Figure 1.

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Figure 1.

Types of mastectomy incisions: A) Horizontal (skin-sparing mastectomy), B) skin-reducing, C) nipple-sparing, inframammary, and D) nipple-sparing, radial incision.

Options for breast reconstruction.

Options for breast reconstruction are divided into alloplastic (implant-based) or autologous (tissue-based) reconstruction (Table 2). Implant-based reconstruction is currently the most common type of breast reconstruction performed in North America.¹² Substantial improvements made in both implant technology and techniques have allowed for aesthetically pleasing, efficient, and safe reconstruction in most breast cancer patients. Likewise, advances, particularly in the field of microsurgery, have provided options for transfer of tissue from various body areas with minimal donor-site morbidity. Both categories of breast reconstruction can be performed in an immediate or delayed fashion.

Alloplastic implant-based reconstruction: Alloplastic reconstruction (Figure 2) is traditionally performed in 2 stages involving insertion of a tissue expander followed by implant exchange. A “direct-to-implant” approach allows reconstruction with the permanent implant at time of mastectomy. Table 3 provides guidance for deciding between these approaches. Alloplastic reconstruction involves shorter surgeries with easier recovery but with the possible need for ongoing implant monitoring or adjustment in the future. Surgery can take 1 to 2 hours per side, and return to normal activity is expected within 2 to 3 weeks. Exercise and heavy lifting are restricted for 6 weeks.

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Figure 2.

Types of alloplastic implant-based reconstruction: A) Two-stage reconstruction; B) direct-to-implant reconstruction.

Autologous tissue reconstruction: Autologous reconstruction (Figure 3) uses the patient’s own skin, fat, and muscle to reconstruct the breast mound. Broadly, autologous reconstruction is divided into pedicled versus free flap. The advantages and disadvantages of each are described in Table 4. Pedicled flaps originate from tissue close to the breast and use native blood supply to vascularize the breast mound. Examples of pedicled flaps include the latissimus dorsi flap and the pedicled TRAM (transverse rectus abdominis myocutaneous) flap. Alternatively, free flaps can be taken from close or remote areas. They are disconnected from their native blood supply and reconnected in the breast area via specialized microvascular techniques. The most commonly used example is the DIEP (deep inferior epigastric artery perforator) flap, which uses skin and subcutaneous tissue of the abdomen supplied by the DIEP blood vessels to create the breast mound. Common autologous breast reconstruction types are described in Table 5.

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Figure 3.

Autologous breast reconstruction: A) and B) abdominal-based reconstruction; and C) latissimus dorsi reconstruction.

Autologous reconstruction involves longer surgery with donor- and recipient-site involvement. For this reason, return to sedentary activity (eg, walking or sitting for prolonged duration) is usually 2 weeks, but with restriction in many activities for up to 8 weeks. A hospital stay of 1 to 4 days is generally required.

Fat grafting in breast reconstruction: Autologous fat grafting (Figure 4) involves harvesting fat from a remote body area via liposuction followed by injection with small cannulas into the breast area. Most commonly, it is used for refinement and optimization, as an adjunct for both types of breast reconstruction,¹³ or to fill partial mastectomy defects.¹⁴ It is currently being used in select cases as the primary method for whole-breast reconstruction. As a filler material it is favourable owing to its availability, ease of harvest, and biocompatibility.¹³ The abundance of adipose-derived stem cells within the transferred fat also gives the fat great potential to repair breast tissues damaged from surgical trauma or radiation. This technique has extended the options of reconstruction in many patients who would have previously been poor candidates. It has been shown in many studies to be safe and compatible with surveillance imaging¹⁵ and it does not influence the risk of cancer recurrence.^16,17

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Figure 4.

Fat grafting for lumpectomy defect reconstruction

Lumpectomy defect reconstruction: As an alternative to mastectomy, many women undergo breast conservation therapy (BCT). Breast conservation therapy includes lumpectomy followed by radiation and provides equivalent long-term survival compared with mastectomy.^18,19 While this approach leaves most of the breast intact, up to 40% of patients can have unsightly and deforming breast abnormalities following BCT.^20–23 The new field of oncoplastic surgery combines the lumpectomy with immediate rearrangement of adjacent tissues to preserve the ideal breast shape. In many cases, the contralateral breast will be balanced at the same time through breast reduction or lift (Figure 5). Although possible through autologous fat grafting, transfer of autologous tissue flaps, or local tissue rearrangement,²⁴ reconstructing these defects in a delayed manner is far more difficult. This highlights the need to consider plastic surgery involvement early in the decision to undergo BCT when a large defect is possible.

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Figure 5.

Oncoplastic breast reduction

Nipple-areolar reconstruction: Reconstruction of the nipple-areolar complex (NAC) (Figure 6) is the last step of breast reconstruction and is usually undertaken when the breast mound has healed and settled in its final position. Restoration of the NAC includes reconstruction of the projecting nipple and pigmentation. For nipple reconstruction, local skin flaps can be designed and folded to produce a projecting nipple, a graft can be harvested from the contralateral nipple, or a 3-dimensional tattoo can be used to give the illusion of a projecting nipple. Pigmentation of the NAC can be obtained via tattoo or skin graft.^25,26 Patients are generally very satisfied with NAC reconstruction, although a lack of long-term nipple projection is a common problem.²⁷ These procedures are often completed under local anesthesia in an outpatient setting.

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Figure 6.

Nipple areolar reconstruction: A) Three-dimensional tattoo, B) nipple reconstruction with local flap, and C) tattoo following nipple reconstruction.

Adjunct procedures: For many women, secondary procedures such as fat grafting, implant adjustments or replacements, or skin tightening procedures are required over time. In unilateral cases, balancing procedures such as contralateral breast reduction, augmentation, or mastopexy can be performed in the immediate or delayed setting to achieve appropriate symmetry.

Outcomes and complications

Outcomes: Many recent studies have looked at outcomes, complications, and satisfaction rates after breast reconstruction. Regardless of procedure type, most women find an improvement in quality of life and psychological and emotional well-being, with an improvement in body image, symmetry, and balance. Studies repeatedly demonstrate that, when asked, women who have undergone breast reconstruction indicate they would make the same decision again and would recommend reconstruction to a friend who was facing this decision.^4–7

Complications: Complications specific to breast reconstruction depend on the reconstructive option chosen (Table 6).²⁸ Complications of implant-based reconstruction include capsular contracture (hardening of the internal breast capsule), malposition (improper or changed positioning of the implant), implant rippling or edge visibility, and an unnatural look or feel. Complications more specific to autologous reconstruction include donor-site complications such as wound healing delay, abdominal bulge or hernia, and occasionally donor-site weakness. Difficulties in obtaining good shape, appropriate size, and good symmetry are problems with both implant- and tissue-based reconstruction.

Surveillance following breast reconstruction.

There are no data to support the value of routine screening mammography after mastectomy and reconstruction. Further, there are no data to suggest breast reconstruction hides local recurrence or affects survival.^29,30 The goal of mastectomy is to remove all breast tissue, and if there is a small amount of residual breast tissue it is almost always under the breast skin. Therefore, local recurrences after mastectomy usually present as skin recurrence, as the skin is physically separated from the chest wall by breast reconstruction.^31,32 Clinical examination of the chest wall and reconstructed breast can detect skin recurrences and should be performed during breast cancer survivorship follow-up appointments.^29,33 Cancer Care Ontario recommends diagnostic imaging (such as mammography, ultrasound, and magnetic resonance imaging) primarily for reconstructed breasts of symptomatic patients.^9,34

Funding.

In Canada, most provinces offer postmastectomy breast reconstruction coverage. Refer to the relevant schedule of benefits for more information.^35–43

Patient education.

Many educational resources exist to help patients better understand their options for breast reconstruction. Online and print resources are available from the CCO⁴⁴ and the Canadian Cancer Society⁴⁵ web-sites. An international campaign for breast reconstruction awareness takes place on the third Wednesday of October every year. Additionally, BRA (Breast Reconstruction Awareness) Day events are an excellent resource for patients to learn about options and improve access to breast reconstruction. Education and event information are available online.⁴⁶

Behavioural change.

Given that there are no absolute contraindications for breast reconstruction, surgical optimization can be achieved for women thinking about undergoing the procedure with the support of their PCPs. Strong examples in this realm include smoking cessation and weight loss.