Patient Selection, Timing, and Techniques in Breast Reconstruction

Dr. Şükrü Yazar, Dr. Altuğ Altınkaya Acıbadem Mehmet Ali Aydınlar University, Department of Plastic, Reconstructive and Aesthetic Surgery

Summary Breast reconstruction after mastectomy is on the rise worldwide due to increased awareness, advancements in reconstruction techniques, rising patient satisfaction rates, and changes in mastectomy patterns. Many new techniques have been described to improve patient outcomes in breast reconstruction. This article aims to evaluate the significant aspects of breast reconstruction.

Abstract Postmastectomy immediate breast reconstruction in the world continues to experience pward trend increasing to heightened awareness, innovations in reconstructive technique, growing evidence of improved patient-reported outcomes, and shifts in mastectomy patterns. There are several new techniques defined, that now allow patients to achieve better results. This manuscript will review the salient aspects of breast reconstruction.

ENTRANCE According to the World Health Organization, breast cancer is the most common type of cancer among women. While breast-conserving surgery is now possible in patients diagnosed early, many patients still undergo unilateral or bilateral mastectomy for treatment purposes. When mastectomy was described by Halsted in 1882, it was a radical operation involving the en bloc removal of skin, breast tissue, pectoralis major muscle, and axillary lymph nodes (1). Breast reconstruction techniques that emerged in those years aimed to correct chest wall deformities and post-mastectomy complications resulting from radical mastectomy. With the changes in mastectomy techniques and the development of breast reconstruction techniques over the years, the aim of breast reconstruction today is to create breast tissue in a shape and symmetry that corrects the anatomical defect created after mastectomy without affecting the patient’s oncological treatment. In addition, breast reconstruction improves the psychological state and quality of life of breast cancer patients (2). Therefore, the importance of breast reconstruction has increased and it has become a separate area of interest for plastic surgeons.

In 1895, Czerny’s use of a lumbar lipoma for the reconstruction of a mastectomy defect is considered the first attempt at breast reconstruction (3). In later years, healthy breast tissue was used to reconstruct the mastectomy area in patients who had undergone unilateral mastectomy (4). In the 19th century, local flaps were used to close skin defects that occurred after mastectomy (5, 6). The discovery of silicone implants in 1963 was an important step in breast reconstruction. With Radovan’s description of tissue expanders in 1982, a two-stage technique began to be used in breast reconstruction. In 1976, Olivari’s redefinition of the Latissimus Dorsi flap paved the way for breast reconstruction techniques with autologous tissue. PATIENTS WHO ARE CANDIDATES FOR BREAST RECONSTRUCTION All women who have undergone mastectomy are candidates for breast reconstruction. Therefore, identifying the patient group for whom reconstruction cannot be performed is more important. Patients who do not accept permanent scars, have unrealistic expectations, whose health condition is not suitable for elective surgical operations, and patients with a poor prognosis and low survival expectation (7) constitute the patient group for whom breast reconstruction is not suitable. BREAST RECONSTRUCTION TIMING Simultaneous Reconstruction: This is the simultaneous performance of the reconstruction procedure with mastectomy. Patients diagnosed with ductal carcinoma in situ, Stage 1, Stage 2, and those who will not receive radiotherapy constitute the patient group suitable for simultaneous reconstruction. The advantages of simultaneous reconstruction include a reduced number of surgeries, lower cost, a single-stage recovery period resulting in a shorter hospital stay, and a positive mood due to the absence of loss of self-confidence and body image distortion (8, 9). The most important disadvantage is skin necrosis that may develop as a result of circulatory problems in the mastectomy flap and the complications that may be observed as a result. Simultaneous Delayed Reconstruction: Simultaneous delayed reconstruction is a two-stage reconstruction method in which a tissue expander is placed in the patient at the same time as mastectomy, and then replaced with a permanent implant. Patients suitable for this method are those who have a positive lymph node biopsy result during mastectomy and are planned to receive radiotherapy. By inflating the tissue expander placed at the same time as the mastectomy, the aim is to preserve the natural anatomical features of the patient’s breast. In this way, it is aimed to minimize the negative effects of radiotherapy and to benefit from the advantages of simultaneous reconstruction without disrupting the patient’s treatment process (10). Late-stage reconstruction This is a reconstruction performed at any time after a mastectomy. It is usually expected to occur after the hematological effects of chemotherapy have improved and the skin changes following radiotherapy have stabilized. Its greatest advantage is the possibility of planning according to the changes after radiotherapy. Its biggest disadvantages are the difficulty of reconstruction due to the loss of anatomical features and skin sheath of the patient’s breast, the increased number of surgeries, and the increased costs. RECONSTRUCTION METHODSBREAST RECONSTRUCTION METHODS Breast reconstruction can be performed using four main methods: reconstruction with implants, reconstruction with autologous tissues, reconstruction using a combination of autologous tissues and implants, and reconstruction with fat injection. Implant-based Reconstruction This is the most commonly used reconstruction method today.11 Patients with a low body mass index, those who do not want to undergo numerous surgeries, and patients with small to medium breast volume without ptosis are the most suitable patient group for this method. Although this method is not considered suitable for patients with large breast volume and ptosis, ideal cosmetic results can be obtained in this patient group by placing the implant and simultaneously reducing the breast skin to make it suitable for the implant.

There are two types of implants: 1) Permanent implants 2) Tissue expanders. Permanent implants are implants consisting of a silicone outer shell and silicone gel inside, and their volume cannot be changed. There are two different types of tissue expander implants. They all have a common silicone outer shell; some have a reservoir that can only be filled with saline, while others have a reservoir filled to a certain extent with silicone gel, and the remaining part can be filled with saline. Tissue expander implants have an adaptive port, and inflation is performed with the help of this port. One-Stage Reconstruction with Permanent Implant This method is applicable to patients with good skin blood supply after mastectomy, sufficient integrity of the pectoral and serratus anterior muscles to cover the prosthesis, and a low likelihood of receiving radiotherapy. The implant is placed in a prepared site under the pectoral muscle. Since the pectoral muscle is not sufficient to cover the lateral portion of the implant, the lateral portion of the implant is covered with the serratus anterior fascia. One-Stage Reconstruction with Tissue Expander Implant In cases where skin blood supply is questionable after mastectomy, and the pectoral and serratus anterior muscles are insufficient to cover the prosthesis, a tissue expander implant is placed in the subpectoral lodge to avoid further disruption of skin circulation using a permanent implant, and it is inflated to a volume that does not impair skin circulation. The most popular of these implants are Becker prostheses. Becker prostheses were first used in 1984 and are named after the surgeon who described them (12). This prosthesis consists of two separate lumens nested within each other. The outer lumen is filled with silicone gel, and the inner lumen volume is fixed. The inner lumen is empty and can be inflated by the surgeon during and after the operation with saline until it reaches the desired volume. There are different types of Becker prostheses where the ratio of the silicone gel volume to the total prosthesis volume is 25%-50%.

After the wound healing is complete, the implant is inflated at regular intervals in an outpatient setting until it reaches the desired volume. Once the desired volume is reached, the external port, which allows unilateral fluid flow connected to the tissue expander, is removed through a small incision under local anesthesia, and the reconstruction is complete. Nowadays, there are implants where the port is integrated into the tissue expander. With integrated port tissue expanders, reconstruction can be completed as soon as the implant reaches the desired volume without the need for a second intervention to remove the port. Two-Stage Reconstruction with Tissue Expander Implant The indications for two-stage reconstruction with tissue expander implants are the same as for one-stage reconstruction with tissue expander implants. If this method is applied simultaneously, the aim is to protect the skin sheath from the adverse effects of radiotherapy. The purpose of using this method in the late stages is to expand the insufficient skin sheath with a tissue expander implant. In the second session,

the placed tissue expander implant is replaced with a permanent implant. Reconstruction using a combination of autologous tissues and implants. In cases where the volume of autologous tissue available for breast reconstruction is insufficient, the volume deficiency is corrected using implants. The most important example is the use of implants in conjunction with a latissimus dorsi muscle-skin flap. After the latissimus dorsi flap is passed through a tunnel prepared in the axillary region to the breast region, an implant is placed under the flap to achieve the desired volume, thus completing the reconstruction. Autologous Tissue Reconstruction Despite the fact that autologous tissue reconstruction can create a more natural breast tissue compared to implant reconstruction and the resulting high patient satisfaction, the rates of autologous tissue reconstruction have decreased in recent years (13-14). The biggest factors in this are the need for microsurgical experience, prolonged operation times, and increased hospital costs. In autologous tissue reconstruction, the prepared flap can be transferred to the mastectomy area with a pedicle without disrupting the original blood supply, or it can be prepared in a distant area and transferred to the mastectomy area as a free flap using microsurgical methods. Pedicled Flaps Used in ReconstructionTRAM (Transverse Rectus Abdominis Muscle – Skin Flap) The skin, subcutaneous tissue, rectus fascia and muscle are lifted with the superior epigastric artery and vein pedicle and transferred through a subcutaneous tunnel to the mastectomy site. Here, the flap is shaped to form breast tissue. It is a preferred method in patients with sufficient abdominal tissue, especially those with a body mass index below 30. It is contraindicated in patients who have undergone previous abdominal surgery and in obese patients. There is a risk of laxity, weakness and hernia development in the abdominal region in the postoperative period (15). Latissimus Dorsi Flap Thoracodorsal It can be used with arterial and venous pedicles, as a muscle-only flap, or as a muscle-skin flap. It is tunneled from the axillary region to the mastectomy site. Often, it needs to be used in conjunction with an implant to achieve the desired result. It is a rescue flap in cases of reconstruction with a complicated implant or in unsuccessful autologous reconstructions.

Free Flaps Used in ReconstructionTRAM (Transverse Rectus Abdominis Muscle – Skin Flap) A portion of the abdominal skin, rectus fascia, and muscle is lifted with a deep inferior epigastric artery-vein pedicle. The flap is supplied with blood by anastomosing to the internal mammary vessels or thoracodorsal vessels at the mastectomy site. DIEP (Deep Inferior Epigastric Artery Perforator Flap) is a flap containing the same skin and subcutaneous tissue as the TRAM flap, but unlike the TRAM flap, the rectus fascia and muscle are not included in the flap. One or two vessels (perforating vessels) supplying the skin are dissected down to the deep inferior epigastric pedicle. Since the rectus muscle and fascia are preserved, deformities such as abdominal hernia and weakness, which can be seen after TRAM flap, are observed less frequently (16). SIEA (Superficial Inferior Epigastric Artery Perforator Flap) It contains the same abdominal tissue as the DIEP flap, but the difference is that the feeding pedicle is the superficial inferior epigastric artery. Its biggest disadvantages are that it is technically difficult and can only be applied to 30% of the population (17). SGAP (Superior Gluteal Artery Perforator Flap) This is a perforator flap involving skin and subcutaneous tissue from the upper gluteal region. It is useful in patients who lack sufficient abdominal tissue. An advantage is that the donor area scar can be easily concealed within underwear. Disadvantages include the difficulty of technical preparation and the potential for sciatic nerve damage. IGAP (Inferior gluteal Artery Perforator Flap) This is a perforator flap involving the skin and subcutaneous tissue below the gluteal region. Its indications, advantages, and disadvantages are the same as those of SGAP (Small Gluteal Acid Apnea Cap). Other Free Flaps Used The Transverse Gracilis Perforator Flap is a perforator flap containing skin and subcutaneous tissue from the medial thigh region above the gracilis muscle, supplied with blood from the medial circumflex femoral vessels. The Thoracodorsal Artery Perforator Flap is a perforator flap containing the same skin and subcutaneous tissue as the latissimus dorsi flap, supplied with blood from the thoracodorsal vessels. Reconstruction with Autologous Fat Injection Fat injection is frequently used as a complement to reconstruction with implants to achieve better cosmetic results. Since adipose tissue is a metabolically active tissue, it has been suggested that cytokines, hormones, or growth factors secreted from the injected adipose tissue may increase the oncological risk and cause cancer recurrence. Clinically,

studies have shown that fat injection does not increase the oncological risk (18-20). Furthermore, although it is thought that calcifications observed in the injected fat may make mammographic follow-up difficult, clinical studies have shown that the calcifications observed after fat injection are different from cancer-related calcifications and that an experienced radiologist will not have difficulty distinguishing them (21, 22). In the repair of partial breast defects, fat taken from the patient’s body using thin cannulas is centrifuged and then injected into the defect area using special cannulas. In reconstruction after total mastectomy; Special bras that create negative pressure with vacuum to expand the skin in the mastectomy area are used, and a realistic breast appearance can be obtained by injecting fat under the expanded skin in intermittent sessions (23). Complications that can be observed after fat injection are cyst formation, fat necrosis, microcalcification, infection, palpable nodule formation and contour irregularities, and their incidence varies between 1% and 7% (24, 25). NIPPLE – AREOLA RECONSTRUCTION Many methods exist for nipple and areola reconstruction. The most popular nipple reconstruction methods are the C-V flap, Star flap, and Skate flap, all based on the principle of reconstructing the nipple with transposition flaps that have a local random feeding pattern. In women with a large contralateral nipple, a portion of that nipple can be used in reconstruction. Filler materials or costal cartilage can be used to provide nipple projection (26, 27).

In areola reconstruction, creating a new areola through tattooing is a frequently used method (28).

Less frequently, full-thickness skin grafts taken from the contralateral areola, the medial thigh, or the labial region can be used. PROCEDURES DIRECTED AT THE OPPOSITE BREAST One of the most important aspects after mastectomy, at least as crucial as the reconstruction procedure itself, is ensuring aesthetic harmony between the reconstructed breast and the opposite breast. Procedures related to the symmetry of the opposite breast can be performed simultaneously with or after reconstruction. In women with small breast volume, augmentation of the opposite breast is a suitable option to achieve symmetry, while reduction is appropriate for those with large breast volume. In women with ptotic breasts, mastopexy, mastopexy, and augmentation surgery can be performed to achieve symmetry. SOURCES (1) Halsted WS. I. Ann Surg. The results of operations for the cure of cancer of the breast performed at the Johns Hopkins Hospital from June, 1889, to January, 1894. 1894; 20: 497-555. 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