Breast reconstruction combines all aspects of plastic, reconstructive and aesthetic practice.
The diagnosis of breast cancer can be devastating and the decisions regarding reconstruction are often seen as a secondary consideration. The pros and cons of immediate and delayed reconstruction (after mastectomy) are one of the most challenging that face patients with a diagnosis of breast cancer. A careful discussion with the patient is imperative to guide the patient in the decision making process. This often requires multiple consultations within the context of a multidisciplinary oncological team.
Breast reconstruction can be provided by both autologous and non-autologous tissue and a combination of both techniques. Non-autologous methods of reconstruction include the use of tissue expanders and implants.
Autologous reconstruction uses ones own tissue. The advantages of using ones own tissue is that the tissue ages naturally and the reconstruction changes minimally with time.
Initially an autologous reconstruction may be more time consuming than non-autologous reconstruction in terms of surgical time and recovery, however the benefits often outweigh the risks. It is important to discuss the pros and cons of autologous and non-autologous reconstructions with each patient individually to determine suitability.
For autologous breast reconstruction the gold standard technique is the deep inferior epigastric perforator flap (DIEP), which is a modification of the transverse rectus abdominis muscle flap (TRAM). With newer techniques to protect the muscle and its function (DIEP), tissue from the abdomen can be used to reshape the breast with minimal side effects to the abdomen. The tissue that would normally be excised during a cosmetic tummy tuck is dissected carefully with its blood supply (the diep inferior epigastric artery) to avoid damage to the tummy muscles creating a flap of tissue. Blood vessels in the chest or the armpit are also dissected free and the artery and veins of the veins in the chest and the veins in the tummy tissue are sutured together using fine suture material under a microscope. The tummy is closed in the same way as a tummy tuck or abdominoplasty (link) and the new tummy tissue is reshaped onto the chest wall to create a new breast. The use of tissue from other areas of the body can also be used such as the though and the buttock and the pros and cons of these need to be discussed at consultation. These include the TMG (from the thigh), the SGAP and the IGAP (from the buttock)
Other autologous options for breast reconstruction include the use of tissue from the back (Latissimus Dorsi flap). In this scenario the back muscle and the skin overlying it is passed onto the front of the breast and the back is closed. The back tissue may provide enough tissue to mould a breast shape but often requires an implant.
Implant based reconstruction using autologous or non-autologous dermis may also be used to reconstruct breast tissue. This can be used in patients who wish to have a simple solution following mastectomy in the immediate phase although it is not recommended where patients require radiotherapy or where a mastectomy has already been performed.
The most important aspects of breast reconstruction include size, shape and symmetry. The initial operation provides the basis with which the surgeon can mould the final result. Often a second operation is required in order to achieve these goals. With increasing refinements a combination of lip modelling, combining liposuction (removal of fat) (link) and autologous fat transfer (injection of fat) (link) the new breast can be remodelled to give an even more natural result. This can be combined with a nipple reconstruction and areola tattooing to give a result that is similar in size, shape and symmetry. In unilateral reconstruction it may be necessary to perform surgery to the unaffected breast to give symmetry. This is often in the form of a mastopexy (link), breast reduction (link) or mastopexy implant (link)
The advent of microsurgery in the field of plastic, aesthetic and cosmetic practice has made the provision of this form of autologous reconstruction more widely available. Although it is not suitable for everyone and can never replace the original breast tissue, those that choose this form of surgery benefit from longer lasting breast aesthetics and abdominal contour.
With all aesthetic surgery autologous breast reconstruction is not without its inherent risks and these need to be discussed with surgeons experienced in providing this highly specialised form of breast reconstruction.
The reconstructions need to be tailored to each patients individualised needs following discussion regarding the pros and cons of each technique.
Breast Reconstruction following lumpectomy
Following lumpectomy there may be asymmetry between the breasts. Common treatments include the use of autologous fat transfer (link) or reshaping the affected breast in the form of a mastopexy (link). Where asymmetry is more marked there may also be a need to combine these and perform surgery on the unaffected breast to aid symmetry in terms of volume (breast reduction link). Occasionally autologous and non-autologous methods of reconstruction can be used to help reconstruct defects following lumpectomy as described above. In severe cases it may be necessary to complete a mastectomy in order to obtain a pleasing aesthetic result.