Jennifer F. Waljee
Amy K. Alderman
Presentation
A 42-year-old female presents to her primary care provider after noticing a firm, 2-cm mass in the upper outer quadrant of her left breast. She underwent ultrasound and mammography that revealed a spiculated 2-cm lesion in the upper outer quadrant of her breast with a BiRADs classification of 5. She underwent core needle biopsy revealing an invasive ductal carcinoma. Axillary ultrasound and clinical examination was negative for any suspicious lymph nodes.
She has no other past medical or surgical history. Her only medications include a proton pump inhibitor and an antidepressant. She is a nonsmoker with three children and is employed as a third grade teacher. She has no other relevant family or social history. She currently wears a C cup bra size and desires to remain the same size.
She has met with a surgical and medical oncologist prior to her consultation with plastic surgery. She is in the process of deciding between breast-conserving therapy including segmental breast resection with adjuvant radiation therapy or simple mastectomy. She will undergo sentinel lymph node biopsy at the time of her breast resection with a possible axillary lymph node dissection depending on the results of the biopsy. She presents today to discuss her options for breast reconstruction.
Discussion
In the modern era, many women diagnosed with breast cancer are candidates for breast reconstruction. Reconstruction following breast cancer resection is safe and does not delay adjuvant therapy or diagnosis of cancer recurrence. It is correlated with improved psychosocial functioning, body image, and mental health outcomes following cancer treatment. Nonetheless, prior research indicates that many women are not referred for reconstruction who may be appropriate candidates. Therefore, it is important to incorporate a routine discussion of breast reconstruction into preoperative surgical planning for women diagnosed with breast cancer. This chapter will discuss the current reconstructive options for breast reconstruction and will explain how to appropriately evaluate patients for these procedures.
Workup
Reconstructive surgery corrects anatomic deformities in order to re-create form, function, and symmetry. Breast reconstruction utilizes either autologous tissue flaps or breast implants, and can be performed either at the time of cancer resection or at a later date. Women who undergo either partial or complete mastectomy may be candidates for breast reconstruction. Therefore, breast reconstruction is an important component of multidisciplinary care, and a consultation with a plastic surgeon should be offered at the time of initial surgical decision making for any woman interested in breast reconstruction.
During the initial office visit, the surgeon should elicit a woman’s understanding of breast reconstruction, her preference for type of reconstructive procedure and timing, and her expectations of the reconstructive process and outcome. It is helpful for women to review relevant literature with appropriate illustrations of different types of reconstructive options prior to the clinic visit in order to better guide the discussion and decision for surgery. Specifically, the surgeon should ask if a woman desires immediate or delayed reconstruction, and if she is interested in implant-based or autologous tissue reconstruction. The surgeon should also ascertain what breast size the patient would like to achieve with reconstruction. The surgeon should be aware if a unilateral or bilateral mastectomy is planned. If a unilateral mastectomy is planned, the surgeon should inquire if the patient has any aesthetic concerns regarding the contralateral breast that can be addressed with a symmetry procedure at a later time.
In addition to obtaining a complete history regarding the patient’s breast disease and proposed treatment plan, a thorough evaluation of the patient’s medical, surgical, and psychological history must be undertaken. Specifically, the surgeon should evaluate if there are any contraindications to general anesthesia, including significant cardiac or pulmonary disease. Additionally, any condition that may impair wound healing, such as diabetes, collagen vascular disease, rheumatologic diseases, or renal failure, may be relative contraindications to elective reconstructive surgery. Morbidly obese patients also have an increased risk for surgical complications with both implant and autologous reconstruction. Nicotine use is a contraindication to reconstruction due to impaired wound healing, and patients should refrain from smoking for at least 1 month prior to any reconstruction procedure. Women who are actively smoking at the time of reconstruction suffer from an increased risk of mastectomy skin flap necrosis, infection, fat necrosis, flap loss, wound dehiscence, and donor site complications. Urine cotinine levels can be obtained to ensure that systemic levels have declined. The patient’s medications should be reviewed, specifically for immunosuppressant medications or anticoagulants. Aspirin, nonsteroidal anti-inflammatory agents, and clopidogrel should be discontinued at least 7 to 10 days prior to surgery. Homeopathic medications such as garlic, ginseng, ginko biloba, ginger, St. John’s wort, Echinacea, and other vitamin supplements should be stopped within 1 to 2 weeks of the operation as well due to the increased risk of bleeding.
The surgeon should obtain complete information regarding the patient’s cancer diagnosis, including the type of mastectomy planned and the need for lymph node sampling or removal. For example, women with locally advanced cancers or clinically present nodal disease are likely to require radiation therapy. Radiation therapy can result in atrophy or fat necrosis of autologous reconstructive procedures and can result in delayed healing, capsular contracture, implant extrusion, and increased rates of infection for women undergoing expander/implant–based reconstruction. Additionally, the surgeon should ascertain if a woman has a strong family predisposition for cancer, such as presence of the BRCA gene, which may increase the possibility that she will undergo bilateral rather than unilateral mastectomy. Finally, the tumor biology is an important consideration, as women with certain diagnoses, such as lobular carcinoma in situ (LCIS), may be counseled toward bilateral rather than unilateral mastectomy.
On physical examination, the patient’s blood pressure and heart rate should be examined, as postoperative hypertension may increase the risk of hematoma formation. The patient’s body mass index (BMI) should be obtained, which may influence her reconstruction options. Obesity increases the risk of autologous flap loss, mastectomy skin flap necrosis, and donor site complications. The surgeon should examine both breasts for size, incisions, degree of ptosis, and symmetry. The chest wall skin should be examined for radiation therapy–related skin changes and evidence of pectoralis muscle atrophy. Potential autologous tissue donor sites should be examined. The abdomen should be examined for the presence of any scars, abdominal wall laxity or rectus diastasis, and the presence of hernias. Paramedian and subcostal incisions may jeopardize the vascular supply of either the flap or the remaining abdominal wall skin. The chest wall should be examined for the presence of axillary or thoracotomy incisions that may damage the integrity of the latissimus dorsi muscle. The strength of the latissimus can be tested by asking the patient to adduct their arm against resistance.
For the patient in this scenario, on physical examination, she is awake, alert, and oriented. Her BMI is 28. Examination reveals pendulous breasts with grade 2 ptosis bilaterally and approximately C cup size. She has a small scar related to her core needle biopsy in the upper outer quadrant of her left breast. She has no abdominal wall scars, and no abdominal wall laxity, hernias, or rectus diastasis. She has normal strength in her upper extremities, and no evidence of pectoralis or latissimus dorsi atrophy.
Treatment Options
Types of Reconstruction
Breast Prostheses
Breast prostheses are ideal options for those women who are not appropriate candidates for breast reconstruction due to comorbid conditions or other factors, or who do not desire reconstruction. Breast prostheses are simple and convenient to obtain, and provide a satisfactory aesthetic result under most clothing options. These prostheses can be custom fit and are covered by insurance.
Breast Implant Placement Following Tissue Expansion
Permanent implant placement at the time of mastectomy is typically not possible as the skin flaps may be inadequate to cover the implant without tension, and the vascularity of the remaining skin may be tenuous with the trauma of mastectomy. Therefore, the risk of postoperative skin necrosis, dehiscence, and implant extrusion is high, and the long-term aesthetic appearance is poor related to contraction and scarring of the skin envelope. While immediate implant placement following mastectomies is occasionally performed, this option is typically limited to specialized centers in a small, select population of patients such as those undergoing nipple-sparing mastectomies
For the above reasons, permanent implant placement is accompanied by a period of tissue expansion prior to final implant placement in order to develop an appropriate skin envelope. Ideal patients are within the normal range of body mass index (BMI) who will undergo bilateral breast reconstruction and have not received or will not receive radiation therapy. It is more difficult to achieve symmetry in patients who will undergo unilateral reconstruction if the contralateral breast is ptotic. Reconstruction is typically performed in two phases. In the first phase, a tissue expander is placed underneath the pectoralis major muscle, with additional inferior coverage using either serratus anterior or acellular dermal matrix. The tissue expander is then sequentially inflated during postoperative visits in the office using sterile technique to the patient’s desired volume, and then overexpansion is performed by 30%. The expander is then left in place for about 2 months, and then exchanged for a permanent saline or silicone implant. Tissue expanders are textured devices with an integrated valve, and are available in a range of shapes and sizes depending on the surgeon’s preference and the patient’s body habitus.
Indications for tissue expander reconstruction are those patients who desire a more expedient postoperative recovery and who are not candidates or do not desire autologous reconstruction due to donor site morbidity. Disadvantages include implant-related problems including contracture, rupture, and malposition. Additionally, implant reconstructions may have a less natural feel compared with autologous tissue, as well as appearance, including rippling of the implant. Contraindications to tissue expander and implant reconstruction include inadequate skin and pectoralis coverage to support expansion and implant placement. Radiation therapy has been correlated with higher rates of wound infection, implant extrusion, and capsular contracture. Therefore, women who have received radiation therapy will require additional muscle coverage using a latissimus dorsi myocutaneous flap on the radiated side if they desire implant-based reconstruction. This is typically performed once radiation therapy is complete and skin changes have stabilized.
Today, both saline and silicone implants are used for breast cancer reconstruction and both are equally safe. In 1992, the United States Food and Drug Administration placed a moratorium on the use of silicone implants due to the concern for increased risk for systemic illness related to the use of silicone. However, multiple studies have failed to show an increased risk of systemic illness, and these regulations have been discontinued. However, silicone implants are contraindicated in women younger than 22 years of age, and current guidelines suggest that women who receive silicone implants have a baseline MRI in 3 years following placement, and then every 2 years for the length of time that the implant is in place.
Autologous Tissue Reconstruction
Abdominal Wall Tissue Transfer. The transverse rectus abdominus myocutaneous flap, or TRAM flap, is the most commonly used flap for autologous breast reconstruction. In this approach, the infraumbilical skin and subcutaneous tissue is transferred to the chest wall defect, using the deep epigastric vessels through the underlying rectus muscle as the vascular supply. This procedure can be performed using a pedicled approach (Figure 1A,B), a bilateral pedicled approach (Figure 2), or microvascular techniques for free tissue transfer (Figure 3). The pedicled TRAM flap is based on the superior deep epigastric vessel, and sacrifices the entire rectus abdominus muscle and overlying fascia during transfer. As the superior epigastric vessel is less robust compared with the inferior epigastric vessels, a delay procedure can be performed 2 weeks prior to flap elevation and inset by ligating the deep inferior epigastric system. This allows the vascular choke vessels to dilate to improve the vascularity and venous drainage of the flap, and should be performed in high-risk patients such as those with diabetes, smokers, and obese patients. A “free” TRAM utilizes the deep inferior epigastric vessels, and allows for richer vascularity and a larger volume of tissue to be transferred as these vessels are more robust. The deep inferior epigastric vessels are anastomosed using microsurgical technique to the thoracodorsal system in the axilla or the internal mammary vessels in the chest wall. Although there is a risk of complete flap loss with this approach, a minimal amount of rectus abdominus muscle and fascia is required with this approach, which minimizes donor site morbidity and abdominal wall weakness. Finally, the rectus muscle can be completely spared using the deep inferior epigastric perforator (DIEP) flap, in which the perforating vessels off of this vascular system are dissected completely from the rectus muscle and transferred to the chest wall defect as a free flap. These flaps have been shown to yield longer pedicle lengths and less abdominal wall morbidity, but have a risk of complete flap loss of around 1% depending on the surgeon experience and are technically demanding with long operating room times required.
FIGURE 1 • A: Design and inset of a pedicled unilateral transverse rectus abdominus myocutaneous (TRAM) flap. B: The final location of scars following a unilateral TRAM. (From the Section of Plastic Surgery, Department of General Surgery, University of Michigan, with permission.)
FIGURE 2 • Design and inset of a pedicled bilateral transverse rectus abdominus myocutaneous (TRAM) flap. (From the Section of Plastic Surgery, Department of General Surgery, University of Michigan, with permission.)
FIGURE 3 • The “free” TRAM technique by performing a microscopic anastomosis of the deep inferior epigastric vessels to the thoracodorsal artery and vein. (From the Section of Plastic Surgery, Department of General Surgery, University of Michigan, with permission.)
Latissimus Dorsi Myocutaneous Flap. The latissimus dorsi muscle can be used as a myocutaneous, or a muscle-only flap for breast reconstruction in women who have undergone partial or complete mastectomy. The latissimus dorsi flap can be used without an implant in women who have undergone partial mastectomy with defects or asymmetry requiring reconstruction. The latissimus dorsi is typically used in conjunction with a permanent implant following a period of tissue expansion in women who undergo complete mastectomy (Figure 4), with the exception of a small percentage of patients who undergo an “extended” technique. This technique incorporates the deep layer of subcutaneous fat beyond the borders of the muscle, which can provide sufficient volume to avoid the use of an implant. Patients who have undergone prior thoracotomy are not candidates for this flap as the muscle has been divided, and patients who have previously undergone axillary node dissection should be considered for CT angiography to ensure the patency of the thoracodorsal artery. Sacrifice of the latissimus dorsi results in minimal functional deficit for women except in certain competitive athletes. The latissimus dorsi flap can be performed at the time of the mastectomy, can be used for bilateral reconstruction, and is ideal for women who may not be candidates for TRAM reconstruction due to abdominal wall obesity.
FIGURE 4 • The latissimus dorsi myocutaneous flap. (From the Section of Plastic Surgery, Department of General Surgery, University of Michigan, with permission.)
Other Perforator Flaps. The advent of microsurgery has allowed the development of a number of other perforator flap options for breast reconstruction. For example, perforators from the superior gluteal artery and inferior gluteal artery systems can be used to create autologous flaps in women who may not be candidates for implant-based or abdominal wall autologous reconstruction options. Additionally, a myocutaneous flap from the deep circumflex iliac vessels (the “Rubens” flap), the anterior lateral thigh flap, and the transverse upper gracilis myocutaneous flap are all other options for free tissue transfer for breast reconstruction. Finally, in a small percentage of women, the superficial inferior epigastric artery can support the lower transverse skin island and subcutaneous tissue for breast reconstruction, the SIEA flap. This flap is advantageous over flaps utilizing the deep inferior epigastric system in that they avoid the need to harvest vessels below the abdominal wall fascia, minimizing abdominal wall morbidity. Although not as widely performed, these options are gaining popularity at specialty centers and are important options for women who cannot undergo implant or abdominal-based autologous reconstruction.
Surgical Decision Making and Approach
Timing of Reconstruction
Women who are not appropriate candidates for reconstruction or who do not wish to undergo the reconstructive process can be referred for breast prostheses, which can allow them to regain form in clothing without undergoing a surgical procedure. Women should be counseled that the process of breast reconstruction spans several months, and even years, and she should approach this journey fully informed of the risks, benefits, and limitations of reconstruction. Complete reconstruction, regardless of which type is selected, will require multiple operative procedures, each of which requires a postoperative recovery period of 3 to 12 weeks depending on the type of reconstruction selected. Thus, it is not a decision that should be taken lightly, and is often difficult for women to process the implications of reconstruction at the time of their diagnosis and initial decision for surgery. Therefore, some women may opt to defer reconstruction until a later time. The advantages of immediate reconstruction include fewer operative procedures, lower associated costs, and the ability to take advantage of skin-sparing mastectomy techniques. Immediate reconstruction occurs at the same procedure as the mastectomy, and can yield improved psychosocial functioning following the procedure due to less psychological distress. Furthermore, the aesthetic result may be better following immediate reconstruction due to less retraction of the skin envelope, although this is controversial. Immediate reconstruction is more efficient as the patient typically undergoes fewer operative procedures, the mastectomy defect does not require re-creation, and the risks of general anesthesia are minimized with fewer procedures. However, if postoperative complications occur, such as infection or delayed wound healing, these may delay adjuvant therapy until these issues have completely resolved. Immediate reconstruction may also be challenging if residual disease is identified in the surgical specimen, which may require reoperation or unplanned radiation therapy.
Delayed reconstruction can be undertaken any time after the mastectomy and adjuvant therapy is complete. Delayed reconstruction is advantageous in that the hematologic and immunologic effects of any chemotherapy are resolved. Some studies suggest that the overall complication rate following reconstruction is lower compared with immediate reconstruction and with a diminished need for blood transfusions. Finally, delayed reconstruction may be associated with improved postoperative quality of life and satisfaction with the aesthetic result, likely due to differences in psychological adjustment with the mastectomy defect.
Radiation therapy is historically considered to be a contraindication to implant-based reconstruction. Although there are some studies that suggest that implant-based reconstruction may be performed in an irradiated field, radiation increases the risk of capsular contracture, delayed wound healing, implant extrusion, and infection. Because of the skin changes related to radiation therapy, the overlying mastectomy flaps do not expand normally and can result in chest wall deformity due to noncompliance of the skin. Therefore, women who have or who are anticipated to have radiation therapy should be counseled toward delayed autologous reconstruction.
Technical Aspects
Tissue Expander/Implant Reconstruction (Table 1)
Preoperatively, the midline of the chest is marked, as well as the inframmamary fold. The breast width is measured to select the expander of the appropriate base width. The skin envelope is examined following the mastectomy, or the skin flaps are re-created if the procedure is being performed in a delayed fashion. The tissue expander is placed in a subpectoral position (Figure 5). The lateral edge of the pectoralis major muscle is identified and elevated using cautery, and the muscle is elevated from the chest wall. Care is taken to identify perforators of the internal mammary vessels medially, which should be controlled with cautery to prevent a postoperative hematoma. Additionally, the vascular pedicle to the pectoralis major, the thoracoacromial vessels, is identified along the underside to the muscle at the midpoint of the clavicle. Care is taken to protect this structure. The pectoralis minor muscle is identified superiolaterally and is left adherent to the chest wall. Care is taken to avoid dissection outside of the boundaries of the breast, specifically laterally, medially, and inferiorly in order to prevent migration of the tissue expander. Excessive dissection medially can result in synmastia, and laterally can result in inappropriate expansion of axillary tissue. Violation of the inframammary fold can result in migration of the expander inferiorly and expansion of abdominal wall tissue. The pectoralis muscle is elevated off of the chest wall inferiorly, and the dissection is transitioned into the subcutaneous space down to the level of the inframammary fold. The expander should have complete coverage, which is accomplished via elevation of the medial aspect of the serratus anterior muscle, or by the placement of acellular dermal matrix (ADM). The selected tissue expander is then placed in the subpectoral pocket, and the pocket is closed using absorbable sutures to close the pocket in an interrupted fashion by closing the edge of the pectoralis muscle to the serratus anterior (or ADM if this approach is selected). A drain is placed in the mastectomy pocket if immediate reconstruction has been performed or in the subpectoral pocket if delayed reconstruction is being performed. The pocket is irrigated with antibiotic irrigation and inspected for hemostasis. Fluid may be cautiously placed in the expander at the time of the operation if there is no tension on the muscle or skin closure. However, if there is any tension or concern for skin flap compromise, this should not be performed. Finally, the tissue expander has a magnetic port for postoperative filling, and the placement of this should be confirmed at the completion of the skin closure to make sure there is no difficulty with postoperative filling. Sterile tapes and a fluff dressing are placed over the incisions, but constrictive dressings are avoided to prevent compression on the skin flaps that could result in necrosis.
TABLE 1. Key Technical Steps and Potential Pitfalls to Tissue Expander and Breast Implant Reconstruction
FIGURE 5 • Placement of the tissue expander/implant into a subpectoral pocket. (From the Section of Plastic Surgery, Department of General Surgery, University of Michigan, with permission.)
Tissue expansion can begin as an outpatient once the drains have been removed and the patient is steadily healing, at approximately 2 weeks postoperatively. This is performed in the office using sterile techniques, and the expanders are filled sequentially at weekly intervals depending on the patient’s tolerance (Figure 6A,B). The expanders are filled beyond the desired implant size by approximately 30%, and then left in place for about 2 months.
FIGURE 6 • A,B: Accessing the tissue expander for inflation. (From the Section of Plastic Surgery, Department of General Surgery, University of Michigan, with permission.)
At that time, exchange can be performed of the tissue expanders for permanent implants. In the preoperative holding area, similar skin markings are used, and the chosen implants can be placed through the previous incisions. The skin is incised, and the subpectoral pocket is entered. The tissue expander is removed, and the pocket is inspected for constrictive scar bands. A capsule of scar will form around the tissue expander, and this is incised (capsuolotomies) or excised (capsulectomies) to release the skin envelope and allow for better skin draping over the implant. A temporary sizer implant is then placed in pocket and the patient is brought to a sitting position. The skin envelope is then readjusted using tailor-tacking techniques, and the breasts are inspected for symmetry in size, contour, shape, and position. The inframmamary fold can be readjusted or defined using sutures, and the implant can be centralized along the chest wall by placing lateral sutures in the breast pocket. The pocket is then thoroughly irrigated, and the final implant is placed. The pocket is closed with absorbable suture, and the skin is closed in a layered fashion. Drains are not placed for the final implant exchange.
Transverse Rectus Abdominus Myocutaneous Flap (Table 2)
Preoperatively, the patient’s chest wall is marked at the midline, as well as along the inframammary fold. The breast width is measured, and then an elliptical incision along the infraumbilical skin is created incorporating this width. A pinch test is used to ensure that this skin defect can be closed without tension. Elevation of the TRAM flap can be performed at the same time or following the mastectomy. The skin incisions are created, and the skin and subcutaneous tissue is elevated to the lateral row of perforators on the side of the muscle pedicle for a unilateral reconstruction. On the opposite side, the perforators are sacrificed and the dissection proceeds across the midline to the medial row of perforators of the muscle pedicle. The fascia overlying the rectus abdominus is divided sharply lateral to the perforators, and the inferior epigastric vessels are identified and ligated. The rectus muscle is carefully dissected out of the rectus sheath, taking care not to damage the rectus fascia, particularly at the tendinous inscriptions. The intercostal nerves are clipped and divided sharply. Once the rectus muscle has been circumferentially dissected inferiorly, the muscle is divided inferiorly and then the dissection proceeds superiorly to the costal margin to the superior epigastric vessels. These vessels are identified and protected. A subcutaneous pocket is created along the medial aspect of the inframammary fold for delivery of the flap with a width of approximately 4 fingerbreadths. The flap should fit easily through the tunnel without concern for strangulation of the vascular pedicle. The flap is then rotated 90 degrees into the mastectomy defect. The flap is then contoured to fit the defect with respect for need for the skin defect and volume requirement. The flap is inset using absorbable sutures. The recuts sheath is closed using a running, large absorbable suture and may be reinforced with an overlay of mesh or ADM if there is excessive tension. The contralateral rectus sheath may be similarly plicated for symmetry. The abdominal incision is then closed by reapproximating Scarpa’s fascia, the dermis, and the epidermis in three separate layers. The umbilicus is delivered through a U-shaped incision along the midline of the abdomen to lie at the level of the anterior superior iliac spines. The operating room table is placed in a flexed position to facilitate closure, and the patient is brought to a sitting position to facilitate inset of the TRAM flap.
TABLE 2. Key Technical Steps and Potential Pitfalls for Transverse Rectus Abdominus Myocutaneous (TRAM) Flap Breast Reconstruction
If the flap is to be performed using microvascular techniques as a “free” flap, the deep inferior epigastric artery and vein are used as the dominant pedicle. Varying degrees of rectus abdominus muscle can be harvested with this flap, which can limit postoperative abdominal wall morbidity. The skin markings are designed as above, and the skin is incised along the ellipse. The initial flap dissection proceeds as above, but care is taken to meticulously dissect the deep inferior epigastric artery and vein without creating trauma to the vessel. These are dissected and ligated between clips as proximally as possible. The vessels are not ligated until the recipient site is completely dissected and prepared, so as to minimize warm ischemia time. The mastectomy pocket is dissected laterally into the axilla if the thoracodorsal vessels are selected as the recipient, or medially if the internal mammary vessels are selected. These vessels are circumferentially dissected using loupe magnification, and adequate length is dissected for ease of the anastomosis. Once this is prepared, the flap is then brought to the recipient site and temporarily tacked in place for stability during the anastomosis. The anastomosis is performed under the operating microscope, and performed typically in an end-to-end fashion. Once this is complete, and adequate inflow and outflow are confirmed, the flap is then inset as described above, and the abdomen is closed in a similar fashion. Patients are typically maintained on antiplatelet therapy (aspirin), and occasionally with heparin anticoagulation depending on the surgeon’s preference.
Latissimus Dorsi Myocutaneous Flap (Table 3)
The patient’s chest and back are marked preoperatively to identify the following landmarks: the chest midline, the inframammary fold, the posterior axillary line, the tip of the scapula, the spine, and the posterior iliac crest. A skin island measuring approximately 8 cm by 15 cm long can be designed in an oblique fashion, which can be concealed in most clothing. Flaps wider than 8 cm may be difficult to close without tension. The most posterior apical point of the axilla is used as a fulcrum to ensure that the flap will rotate into the mastectomy defect without difficulty.
TABLE 3. Key Technical Steps and Potential Pitfalls for Latissimus Dorsi Muscle Myocutaneous Flap Breast Reconstruction
The patient is placed in the lateral decubitus position with the shoulder abducted in order to provide adequate exposure of the posterior thorax and axilla. The latissimus dorsi muscle is a broad, flat, triangular-shaped muscle that measures approximately 25 × 35 cm. It originates from the thoracolumbar fascia, the posterior iliac crest, and the lower six thoracic vertebrae, and inserts on the intertuberular groove of the humerus. The thoracodorsal artery and vein from the subscapular system are the primary vascular supply, but paraspinous perforators also supply the muscle posteriorly. The flap is raised by incising the skin paddle and dissecting down to the muscle fascia beveling away from the skin paddle. The skin and subcutaneous tissue is then elevated off the muscle by carrying the dissection inferiorly to the thoracolumbar fascia, medially to the paraspinous muscles, superiorly to the tip of the scapula, trapezius, and teres major. Posteriorly, the surgeon will encounter the perforating vessels at the paraspinous muscles, and these should be well controlled with cautery to prevent postoperative hematoma formation. The dissection is then carried anteriorly toward the edge of the latissimus, and the muscle is elevated from the serratus and the chest wall. The deep surface of the muscle is carefully dissected at the middle third, and progresses superiorly taking care to identify the thoracodorsal artery and vein and the serratus branch. The pedicle will enter the posterior surface of the muscle approximately 10 cm below its insertion on the humerus. The medial aspect of the muscle is then dissected completely off of the chest wall, and divided as inferiorly as possible in order to allow for advancement of the muscle into the mastectomy pocket. The flap is then tunneled into the mastectomy defect and inset using absorbable sutures tacking the latissimus flap to the pectoralis fascia. A tissue expander is placed under the latissimus flap prior to completing the inset. A drain is placed both in the donor site along the posterior chest and in the mastectomy pocket. The skin paddle of the flap is inset to the mastectomy flaps using absorbable suture in a layered technique, and soft dressing is applied taking care not to constrict the chest in any way and allowing for exposure of the skin paddle to monitor for ischemia or venous congestion.
Special Intraoperative Considerations
If breast reconstruction is to be performed immediately following mastectomy, it is imperative to closely examine the mastectomy skin flaps for signs of impending skin compromise. If there are signs that the mastectomy flaps may not survive, the surgeon should not proceed with reconstruction at that time, but instead wait until the skin flaps have completely declared themselves, as this may change the options for reconstruction.
The thoracodorsal artery and vein should be examined closely if an axillary lymph node dissection has been performed. If this is thrombosed or damaged, this may preclude creation of a latissimus dorsi flap or use of these vessels for free flap anastomosis. Finally, if a flap reconstruction has been performed, the skin paddle of the flap should be inspected closely for evidence of vascular compromise. If this is evidence the pedicle or anastomosis should be examined for evidence of kinking, twisting, or thrombosis, and the overlying skin tunnels should be examined to ensure that they allow for easy passage of the flap without constriction.
Postoperative Management
Following mastectomy and immediate placement of a tissue expander, women are usually discharged home on the day following surgery. Hospital stays are longer for women who undergo autologous tissue flaps, usually ranging from 3 to 5 days. The usual postoperative care is taken, with DVT mechanical and pharmacologic prophylaxis, and encouragement of early ambulation. Women are advised to refrain from driving, strenuous exercise, and household activities for a period of 6 to 8 weeks following reconstruction.
Early complications following breast reconstruction include hematoma, seroma, infection, flap loss, skin necrosis, and implant extrusion. The development of a postoperative hematoma typically warrants operative reexploration as it can increase the risk of skin or flap loss, infection, postoperative asymmetry, and capsular contracture. Infection is a feared complication following tissue expander/implant reconstruction and is treated promptly with antibiotics. Those infections associated with an abscess or who fail to improve on intravenous antibiotics should undergo implant or expander removal. Superficial skin necrosis can be managed conservatively with local wound care. Larger areas of skin necrosis may warrant operative debridement and implant or expander removal. Latissimus flap harvest can result in seroma formation in the donor site, and operatively placed drains may remain for 4 to 6 weeks until their output has dropped sufficiently for removal.
Late complications of breast reconstruction include asymmetry, implant wrinkling, malposition, implant rupture, capsular contracture, and donor site morbidity. Specific to TRAM reconstruction, abdominal wall weakness and hernias are important sources of donor site morbidity. Breast reconstruction revision and implant replacement can be undertaken to resolve these relatively common complications.
The process of breast reconstruction spans a period of months to years. Following reconstruction of the breast mound, further procedures may be desired to revise the shape of the breast, create a nipple, and achieve symmetry with the contralateral breast. Such procedures may include contralateral augmentation with implants or autologous fat grafting, reduction, and mastopexy to achieve symmetry. Finally, nipple reconstruction may be performed as early as 3 to 6 months following breast mound reconstruction, in order to allow for swelling to subside and the breast mound to achieve its final shape. Multiple local flap designs can be used for nipple and areolar reconstruction, and supplemented with tattooing for a more anatomic appearance.
TAKE HOME POINTS
· Many women are candidates for surgical breast reconstruction following partial or complete mastectomy for breast reconstruction.
· Breast reconstruction following mastectomy can improve psychological outcomes following breast cancer treatment and does not interfere with longterm surveillance for recurrence.
· Radiation therapy causes long-term skin changes that impair the ability to successfully expand the skin envelope. These patients should undergo reconstruction with autologous tissue transfer.
· Abdominal tissue transfer utilizing the rectus abdominus can result in hernia formation and truncal weakness. However, innovative perforator-based and muscle-sparing techniques can lessen donor site morbidity and increase reconstructive options for women.
SUGGESTED READINGS
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