Breast reconstruction

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Editors-In-Chief: Martin I. Newman, M.D., FACS, Cleveland Clinic Florida, [1]; Michel C. Samson, M.D., FRCSC, FACS [2]

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Overview

Breast reconstruction is the rebuilding of a breast, usually in women. It involves using autologous tissue or prosthetic material to construct a natural-looking breast. Often this includes the reformation of a natural-looking areola and nipple. This procedure involves the use of implants or relocated flaps of the patient's own tissue.

The primary part of the procedure can often be carried out immediately following the mastectomy. As with many other surgeries, those with significant medical comorbidities (high blood pressure, obese, diabetes) individuals who smoke are higher-risk candidates. Surgeons may choose to perform delayed reconstruction to decrease this risk. Patients expected to receive external beam radiation as part of their adjuvant treatment are also commonly considered for delayed autologous reconstruction due to significantly higher complication rates with tissue expander-implant techniques in those patients.

Breast reconstruction is a large undertaking that usually takes multiple operations. Sometimes these follow-up surgeries are spread out over weeks or months. If an implant is used, the individual runs the same risks and complications as those who use them for breast augmentation but has higher rates of capsular contracture (tightening or hardening of the scar tissue around the implant) and revisional surgeries.

In 1998, the Women's Health and Cancer Rights Act was passed mandating insurance coverage for breast reconstruction in the United States. Prior to this, many insurance carriers did not cover breast reconstructive surgery as they considered it cosmetic in nature. The law is also known as "Janet's Law", named for Janet Franquet, a breast cancer patient who fought her insurance carrier with Dr. Todd Wider, a New York plastic surgeon who helped lobby for the legislation with Senator Al D'Amato. The act mandates insurance coverage for the surgery of the affected breast and also the contralateral side for purposes of symmetry¹.

1. Find more information on mastectomies.

Techniques

There are many methods for breast reconstruction. The two most common are:

• Tissue Expander - Breast implants This is the most common technique used in worldwide. The surgeon inserts a tissue expander, a temporary silastic implant, beneath a pocket under the pectoralis major and serratus anterior muscles of the chest wall. The pectoral muscles may be released along its inferior edge to allow a larger, more supple pocket for the expander at the expense of thinner lower pole soft tissue coverage. The use of acellular human or animal dermal grafts have been described as an onlay patch to increase coverage of the implant when the pectoral muscle is released, which purports to improve both functional and aesthtic outcomes of implant-expander breast reconstruction.

• • In a process that can take weeks or months, saline solution is percutaneously injected to progressively expand the overlaying tissue (see tissue expansion). Once the expander has reached an acceptable size, it may be removed and replaced with a more permanent implant. Reconstruction of the areola and nipple are performed in a separate operation after the skin has stretched to its final size.

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A step-by-step description of the technique using BioMesh follows:

Preoperative Evaluation: At initial consultation, a full history (including breast history), and physical exam (including breast exam and measurements) are obtained. The presence of well established risk factors, for example smoking and radiation, are elicited and discussed. The effect of smoking on mastectomy flaps is well appreciated while the role of biologic material at reconstruction in the previously irradiated breast has not yet been well defined. The patient’s personal goals are established. Methods, risks, benefits and alternatives of breast reconstruction including unilateral and bilateral options as well as materials utilized at surgery are reviewed. Medical evaluation and clearance is requested.

Operative Technique: For patients electing to undergo immediate tissue expander / implant based reconstruction.

1. Evaluation of Mastectomy Flaps:

• Following mastectomy, the skin flaps are evaluated. Poorly perfused margins are débrided. If indicated, reconstruction is deferred and the wounds are closed over drains with the intent of returning to perform reconstruction in a delayed fashion capitalizing on the delay phenomenon. Prior to proceeding with reconstruction, fresh drapes are placed over existing drapes and instruments and light handles are changed.

2. Elevation of the Pectoralis Major Muscle Flap:

• The pectoralis major is detached from its costal origins while the sternal origins are preserved. The muscle is reflected in a superomedial direction. This maneuver is facilitated with electrocautery and establishes the superior portion of the pocket.

3. Preparation of the BioMesh:

• Measurements are checked and adjusted as necessary. The proper size BioMesh is requested and brought to the field.

• In our practice we prefer a BioMesh that does not require rehydration which can be placed in a “package-to-patient” manner. We theorize that rehydration of the BioMesh increases contact with operating room personal; a potential source of contamination. To reduce the risk of contamination, the BioMesh is handled by the operating surgeon only. Additionally, gloves are changed.

• Also, in our practice, we prefer a BioMesh with low elastin content. We theorize that limiting the elastin content may limit the incidence of unwanted stretch.

• Of the currently available BioMesh materials, bovine pericardium satisfies both of these criteria, and is our BioMesh of choice as of this writing.

• To reduce the risk of seroma, the bovine pericardium graft material is fenestrated. This is easily accomplished by making multiple small cuts in a staggered fashion with dissecting scissors. It is our belief that this maneuver reduces the risk of serum becoming trapped between the graft and the mastectomy flap preventing neovascularization and cellular migration.

• The graft is placed within the wound avoiding contact with the skin and oriented along the inframammary fold (IMF).

4. Fixation of the graft to the chest wall:

• The graft is secured to the chest wall reestablishing the inframammary and lateral breast folds.

• The inferior medial and lateral corners are trimmed to approximate a semi-lunar shape to the material.

• Suture material and techniques vary with surgeon preference. In our practice a 2-0 PDS plus ® suture is used in interrupted fashion taking care to burry all knots and suture tails so that perforation of the mastectomy flap does not occur. (

• The neopocket is irrigated with 500 cc of antimicrobial solution, (in our practice, bacitracin, gentamicin, and Ancef) and treated with topical hemostatic agent (thrombin in our practice).

5. Placement of Drains:

• Two #15 round drains are placed. One is placed under the pectoralis muscle to sit posterior to the expander (against the chest wall), and one is placed anterior to the bovine pericardium graft at the level of the IMF.

• Care is taken to tunnel drains subcutaneously with trocars in anticipation of long drain course and they are brought out along the anterior axillary line.

6. Placement of Tissue Expander:

• The tissue expander is selected and brought to the field. Gloves are changed, the field is re-prepped. Air is removed, and the expander is placed under the graft in the neopocket.

7. Inset of the muscle flap:

• The inferior margin of the pectoralis muscle flap is then advanced and approximated to the BioMesh. Again, suture materials and techniques vary, but in our practice a running 2-0 PDS plus ® suture is used.

• The running suture is anchored at the medial margin and run in a medial to lateral fashion. Horizontal bites are taken on the muscle margin to reduce the risk of suture “pull-through.” And, the lateral most bites incorporate the serratus muscle in an effort to close the lateral margin.

• During the inset, lateral tension is placed on the pectoralis muscle to maximize lateral coverage. It is not necessary to put tension on the bovine pericardium as is often recommended with the placement of dermal based grafts. Care is taken not to trap the retro-pectoral drain.

8. Closure and Fill:

• The skin is closed with absorbable sutures. In our practice, 2-0, 3-0 and 4-0 Monocryl plus ® is used. Dermabond ® is placed to insure complete closure and establishment of a microbial barrier.

• Using a closed saline fill system, the expander is then inflated. Goals of expansion include obliterating the dead space and internally bolstering the graft against the mastectomy flap. Care should be taken not to overfill the expander and put pressure on the mastectomy flaps compromising venous return.

9. The final result

• At procedure’s end, the BioMesh is seen reestablishing the inframammary and lateral mammary fold, supporting the expander.

Postoperative Management:

• Close monitoring of the patient in the postoperative phase affords amble opportunity to evaluate the mastectomy flaps.

• If signs of venous congestion appear, fluid can be removed from the expander. If signs of necrosis along the margins appear, a return to the operating room within the first few days for debridement may be indicated.

• Drains are continued until output falls below 20 cc per day, per drain. The use of oral antibiotics while the drains remain in place is surgeon / practice dependent. The drain anterior to the BioMesh is usually removed following the first postoperative week, and the drain posterior to the expander is continued. It may be removed at the end of the second postoperative week or later depending on the quality and quantity of the output.

• Seromas that develop following the removal of drains are aspirated. This, in our opinion, is critical. A seroma which develops between the Biomesh and mastectomy flap will impede neovascularization and cellular migration, and will result in failure of the BioMesh to “take.”

• In most cases, expansion beings at the second or third postoperative week and proceed at a rate of 50 – 150 cc / week depending on goals and patient factors. A waiting period following full expansion allows the mastectomy flaps to mature prior to exchange.

• Flap reconstruction The second most common procedure uses tissue from other parts of the patient's body, such as the back, buttocks, thigh or abdomen. This procedure may be performed by leaving the donor tissue connected to the original site to retain its blood supply (the vessels are tunnelled beneath the skin surface to the new site) or it may be cut off and new blood supply may be connected.
  • The latissimus dorsi muscle flap is the donor tissue available on the back. It is a large flat muscle which can be employed without significant loss of function. It can be moved into the breast defect still attached to its blood supply under the arm pit (axilla). A latissimus flap is usually used to recruit soft-tissue coverage over an underlying implant. Enough volume can be recruited occasionally to reconstruct small breasts without an implant.
  • Abdominal flaps The abdominal flap for breast reconstruction is the TRAM flap or its technically distinct variants the DIEP/SIEP flaps. Both use the abdominal tissue between the umbilicus and the pubis. The DIEP and free-TRAM flaps require advanced microsurgical technique and are less common as a result. Both can provide enough tissue to reconstruct large breasts. The contour of the lower abdomen is reliably improved by these procedures which remove the same tissue as an abdominoplasty (tummy tuck.) TRAM flap procedures may weaken the abdominal muscles, but are usually tolerated well in most patients. To prevent muscle weakness and incisional hernias, the portion of abdominal wall exposed by reflection of the rectus abdominis muscle may be strengthened by a piece of surgical mesh placed over the defect and sutured in place. The DIEP (deep inferior epigastric perforator flap) and SIEP (superficial inferior epigastric perforator flap) require precise dissection of small perforating vessels through the rectus muscle, and purport the advantage of less weakening of the abdominal wall.

The TRAM Flap Procedure
Identification of the target and donor sites	Raising the flap and transposing it to the target site	The result of the reconstruction

Other considerations

Nipple reconstruction is usually delayed until after the breast mound reconstruction is completed so that the positioning can be planned precisely. There are several methods of reconstructing the nipple-areolar complex, including:

• Nipple-Areolar Composite Graft (Sharing) - if the contralateral breast has not been reconstructed and the nipple and areolar are sufficiently large, tissue may be harvested and used to recreate the nipple-areolar complex on the reconstructed side.
• Local Tissue Flaps - a nipple may be created by raising a small flap in the target area and producing a raised mound of skin. To create an areola, a circular incision may be made around the new nipple and sutured back again. The nipple and areolar region may then be tattooed to produce a realistic colour match with the contralateral breast.
• Local Tissue Flaps With Use of AlloDerm - as above, a nipple may be created by raising a small flap in the target area and producing a raised mound of skin. AlloDerm (cadaveric dermis) can then be inserted into the core of the new nipple acting like a "strut" which may help maintain the projection of the nipple for a longer period of time. The nipple and areolar region may then be tattooed later.

One of the challenges in breast reconstruction is to match the reconstructed breast to the mature breast on the other side (often fairly 'ptotic' - droopy.) This often requires a lift (mastopexy), reduction, or augmentation of the other breast.

Follow-up and Recovery

Recovery from implant-based reconstruction is generally faster than with flap-based reconstructions, but both take at least three to six weeks to recover and both require follow-up surgeries in order to construct a new areola and nipple. All recipients of these operations should refrain from strenuous sports, overhead lifting and sexual activity during the recovery period (three to six weeks). TRAM flap patients can show abdominal muscle weakness on EMG studies, but clinically most patients return to normal activities after recovery.

There is little information about upper body exercise post-mastectomy. Issues such as simple mastectomy, mastectomy with reconstruction, mastectomy with lymph node excision and reconstruction all factor into limitations to amount and extent of upper body exercise. Generally, cardiac exercise (treadmill, walking, etc.) are approved for rehabilitation post-surgery and for weight control. Women who have undergone breast reconstruction must still be followed for local or regional recurrence of their cancer with manual exams of the breast/chest wall and axilla.

See also

• Breast reduction
• Breast implant
• Breast lift

External links

• Breast Reconstruction Following Breast Removal from the American Society of Plastic Surgeons
• In-depth breast reconstruction discussion from the University of Iowa
• National Cancer Institute breast cancer page
• NCI online Breast Cancer Risk Assessment Tool for patients
• Surgery Choices for Women with Early-Stage Breast Cancer
• US Dept. of Labor - Women's Health & Cancer Rights Act of 1998

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