Breast reconstruction

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Breast reconstruction is increasing in popularity
Can be performed as immediate or delayed procedure
Breast reconstruction is oncologically safe
Does not delay adjuvant therapy
Does not delay the detection of recurrent disease
There are no absolute contraindications
Relative contraindications are old age, diabetes, smoker, collagen diseases
Preoperative counselling is essential

Reconstructive options

There are three types of breast reconstruction
- Tissue expanders
- Pedicled myocutaneous flaps
- Free tissue transfer
Each has specific uses and complications
The contralateral breast may require surgery to produce symmetry

Tissue expanders

A simple and reliable technique
When used alone often produce a poor cosmetic result
Capsular contracture can result in firmness and discomfort
Capsulectomy and replacement of the implant may be required
Radiotherapy may increase the risk of capsular contracture
Textured implants reduce the risk of capsule formation

Pedicled myocutaneous flaps

The two commonest flaps are:
- The latissimus dorsi flap based on the thoracodorsal vessels
- The pedical transverse rectus abdominis based on the superior epigastric vessels
Either can be performed as an immediate or delayed procedure
Pedicled flaps produce a better cosmetic result
Use of an LD flap is often combined with tissue expander or prosthesis
TRAM flaps often provide enough autologous tissue to avoid the need for a tissue expander
General complications associated with flaps include necrosis and flap loss
The LD flap leaves a scar on the back and some shoulder weakness
TRAM flaps can result in abdominal donor site hernia and weakness

Free flaps

Several flaps have been described based on perforator vessels
Most commonly used is the Deep Inferior Epigastric Perforator (DIEP) flap
Other flaps have been described based on:
- Superficial Inferior Epigastric Artery
- Gluteal artery
Free flaps allow tissue transfer with reduced risk of donor site morbidity
Flap failure rates are higher than with pedicled flaps

Nipple reconstruction

Nipples can be reconstructed by:
- Nipple sharing
- Skate flaps
- Labial grafts
- Nipple tattooing
- Prosthetic nipples

Bibliography

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Antoniuk P M. Breast reconstruction. Obstet Gynecol Clin North Am 2002; 29: 209-223.

Choi J Y, Alderman A K, Newman L A. Aesthetic and reconstructive considerations in oncologic breast surgery. J Am Coll Surg 2006; 202: 943-952.

Corral C J, Mustoe T A. Controversy in breast reconstruction. Surg Clin North Am 1996; 76: 309-326.

Disa J J, McCarthy C M. Breast reconstruction: a comparison of autogenous and prosthetic techniques. Advances in Surgery 2005: 39: 97-119.

Granzow J W. Levine J L. Chiu E S et al. Breast reconstruction with the deep inferior epigastric perforator flap: History and an update on current technique. J Plast Recon Aesth Surg 2006; 59: 571-579.

Malata C M, McIntosh S A, Purushotham A D. Immediate breast reconstruction after mastectomy for cancer. Br J Surg 2000; 87: 1455-1472.

Patel R J, Webster D J T, Mansel R E, Hughes L E. Is immediate post-mastectomy reconstruction safe in the long-term? Eur J Surg Oncol 1993; 19: 372-375.

Pennington D G. Breast reconstruction after mastectomy: current state of the art. Aus NZ J Surg 2005; 75; 454-458

Rainsbury R M. Breast reconstruction - new techniques. In: Taylor I, Johnson C D eds. Recent advances in surgery 22. Churchill Livingstone, Edinburgh 1999. 17-30.