Breast: Breast Reconstruction

General Breast Reconstruction

Methods

  • Prosthetic (Implant-Based) Reconstruction
    • More Common than Autologous Reconstruction
    • Less Invasive
      • Faster Surgery
      • Faster Recovery
  • Autologous (Flap-Based) Reconstruction
    • Uses Own Tissue
    • More Invasive with Longer Recovery
    • Requires Sufficient Excess Tissue for Reconstruction
    • Source: Generally from the Abdomen, Although Occasionally Can Come from the Thigh or Back

Reconstruction Timing

  • Immediate Reconstruction
    • Generally Preferred
    • Contraindication: Future Radiation Therapy
  • Delayed Reconstruction
    • More Difficult Once Tissues Have Healed
    • May Have Worse Cosmetic Outcome

Choice of Reconstruction Method

  • History of Radiation Therapy to the Chest:
    • Autologous Reconstruction is Generally Preferred
    • Permanent Vascular Injury Increases Complication Rates for Prosthetic Reconstructions
    • Risk of Expander Failure: 30-40%
  • Planned Adjuvant Radiation Therapy to the Chest:
    • Options:
      • Delayed Reconstruction Alone (Will Leave Flat Chested for a Period of Time)
      • Temporary Expander with Delayed Removal & Reconstruction
    • Immediate Autologous Flap with Have Irreversible Changes from Radiation & Should Be Avoided
  • No Radiation:
    • Choice Based on Patient Preference

General Complications

  • Pain
  • Hematoma/Seroma
  • Infection
  • Skin Necrosis
    • 18-30% Risk Following Immediate Reconstruction
    • Prevention:
      • Preserve Subdermal Plexus
      • Gentle Retraction of Skin Flaps
      • Minimize Thermal Damage
    • Treatment: Excision of Necrotic Tissue Once Completely Demarcated

Breast Implant 1

Prosthetic (Implant-Based) Reconstruction

Location/Approach

  • Sub-Pectoral Approach
    • Prosthesis is Placed Under the Pectoralis Muscle
    • Immediately Limited Volume Possible Due to Tightness of the Muscle
    • Tissue Expanders Allow Increased Possible Volume Over Time
    • Originally the Approach was Cosmetically Higher than a Normal Breast
      • Now an Acellular Dermal Matrix Can Be Used to Place in a More Normal Location (Requires Cutting of the Pectoralis Muscle Which Can Cause Animation Deformity)
  • Pre-Pectoral Approach
    • Historically was Abandoned Due to Risk for Increased Flap Necrosis/Infection
    • Now Increasing in Popularity Due to Better Skin Flaps Than in the Past

Sub-Pectoral (Left), Pre-Pectoral (Right) 2

Tissue Expanders

  • Initially Placed to Fill the Cavity Prior to Placing the Actual Prothesis
  • Intermittently Filled Over the Course of a Few Months
  • Benefits:
    • Allows Monitoring of Skin Flaps to Ensure Viability Prior to Placing the Definitive Prosthesis
    • Allows Increased Available Volume for Definitive Prosthesis Placement Under the Pectoralis Muscle
  • May Consider Immediate Placement of Prosthesis without Expander if Confident in Flap Vasculature

Tissue Expander Sequentially Filled 3

Prosthetic Types

  • Material:
    • Saline
      • Silicone Shell Filled with Saline
      • Rupture is Generally Safer
    • Silicone
      • Feels More Natural (Most Commonly Chosen by Patients)
      • Possibly Concerned for Increased Risk of Autoimmune Diseases (Still Debated)
  • Shape:
    • Round
      • Smooth Surface without Texture
    • Shaped (Tear-Drop Shape)
      • Requires a Textured Coating to Prevent Migration & Polarity Changes
      • Texture Can Induce a Lymphoproliferative Disorder Which Can Progress to Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL)
      • Generally Avoided Now Due to Concern for Texture

Specific Complications

  • Capsular Contracture
    • Prothesis Develops a Fibrous Capsule
    • Can Present Months-Years After Placement
    • Baker Classification:
      • Class I: Breast Soft with No Palpable Capsule & Looks Normal
      • Class II: Breast A Little Firm with Palpable Capsule but Looks Normal
      • Class III: Breast Firm with Easily Palpable Capsule & Visually Abnormal
      • Class IV: Breast Hard, Cold, Painful & Markedly Distorted
    • Treatment:
      • Initial Management: Massage
        • May Consider Medications (Zafirlukast, Vitamin E & Topical Diclofenac)
      • Open Capsulotomy May Be Required for Class III-IV Disease
        • Total Capsulotomy Preferred Over Anterior-Only (Lower Rate of Recurrence)
  • Rupture
    • Presentation:
      • Saline – Will Reabsorb & Demonstrate Flattening
      • Silicone – Will Stay Localized Causing More Difficulty in Identifying the Rupture
        • Can Migrate Through the Lymph Nodes
    • Monitoring for Silent Rupture: MRI 3 Years After Surgery & Then Every 2 Years for Life
    • Treatment: Excision of Implant
  • Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL)
    • Increased Risk with Increased Degree of Prosthetic Texture
      • Can Still Develop Even After Prosthetic Removal
    • Presentation: A Persistent Delayed Seroma Appearing Years After the Implant Placement
    • Diagnosis: Needle Aspiration of Seroma Fluid
      • Cytology Showing Anaplastic Large Cells & CD-30 T Cells on Flowcytometry
    • Treatment: Surgical Excision (80-90% Success)
  • Breast Implant Illness (BII)
    • Constellation of Nonspecific Symptoms:
      • Autoimmune Disorders (Rheumatoid Arthritis, Sjogren’s Syndrome, etc.)
      • Fatigue
      • Fibromyalgia
    • May Be Associated with Silicone-Based Implants (Debated)

Capsular Contracture 4

Ruptured Implant 5

Autologous (Flap-Based) Reconstruction

Basics

  • Abdominal Wall Flaps are Generally Preferred
  • Transfer:
    • Free Flap: Supplying Vasculature is Transected & Re-Implanted
    • Pedicle Flap: Tissue Moved with Vascular Pedicle Preserved

Abdominal Wall Flaps

  • Transverse Rectus Abdominis Myocutaneous (TRAM) Flap
    • Transfers Skin, Subcutaneous Tissue & Rectus Abdominis Muscles
    • Relies on Superior Epigastric Vessels
    • Higher Risk for Abdominal Wall Diastasis or Hernia Due to Loss of Muscle
    • Best Determinant of Flap Viability: Periumbilical Muscle Perforators
  • Deep Inferior Epigastric Perforator (DIEP)/Fasciocutaneous Flap
    • Transfers Only Skin & Subcutaneous Tissue (Spares Muscle)
    • Better for Donor Site; Fascia Stays Intact
      • Less Pain/Nerve Damage & Lower Hernia Chance
    • Microsurgery – Much Longer
    • Can Provide Good Symmetry if Native Contralateral Breast
  • Superficial Inferior Epigastric Artery (SIEA) Flap
    • Transfers Only Skin & Subcutaneous Tissue
    • Spares the Deep Epigastric Artery – Thereby Avoids Any Muscle Incisions (Compared to DIEP)

TRAM Flap 6

DIEP Flap 6

Posterolateral Flaps

  • Latissimus Dorsi Myocutaneous Flap (LDMF)
    • Transfers Skin, Fat & A Portion of the Latissimus Dorsi Muscle
    • Provides a Smaller Total Volume & Almost Always Requires Additional Implant for Adequate Cosmesis
  • Thoracodorsal Artery Perforator Flap (TDAP)
    • Transfers Only Skin & Fat from the Back

Other Autologous Options

  • Superior Gluteal Artery Perforator (SGAP) Flap
    • Transfers Skin & Fat from the Superior Buttock
    • Muscle-Sparing
  • Inferior Gluteal Artery Perforator (IGAP) Flap
    • Transfers Skin & Fat from the Inferior Buttock
    • Muscle-Sparing
    • Less Common than SGAP
  • Profunda Artery Perforator (PAP) Flap
    • Transfers Skin & Fat from the Upper Posterior Thigh
    • Muscle-Sparing
  • Transverse Upper Gracilis (TUG) Flap
    • Transfers Skin, Fat & Gracilis Muscle from Inner Upper Leg
  • Fat Grafting (Autologous Fat Transfer)
    • Adipose Tissue Removed from Distant Source by Liposuction, Processed into a Liquid & Transferred to the Breast
      • Removed from Abdomen, Thigh & Buttock
    • Transferred Fat is Often Reabsorbed with Loss of Volume Over Time (Often Lose About 50% of Volume)

LDMF Flap 6

References

  1. FDA. Wikimedia Commons. (License: Public Domain)
  2. Dr Roudner. Wikimedia Commons. (License: CC BY-SA-4.0)
  3. Becker H, Lind JG 2nd, Hopkins EG. Immediate Implant-based Prepectoral Breast Reconstruction Using a Vertical Incision. Plast Reconstr Surg Glob Open. 2015 Jul 8;3(6):e412.(License: CC BY-NC-ND-3.0)
  4. Khoo LS, Radwanski HN, Senna-Fernandes V, Antônio NN, Fellet LL, Pitanguy I. Does the Use of Intraoperative Breast Sizers Increase Complication Rates in Primary Breast Augmentation? A Retrospective Analysis of 416 Consecutive Cases in a Single Institution. Plast Surg Int. 2016;2016:6584810.(License: CC BY-4.0)
  5. Dr Oliver. Wikimedia Commons. (License: Public Domain)
  6. Dialani V, Lai KC, Slanetz PJ. MR imaging of the reconstructed breast: What the radiologist needs to know. Insights Imaging. 2012 Jun;3(3):201-13. (License: CC BY-2.0)