As early as 3000 BC, descriptions can be found on Egyptian papyruses documenting reconstructive techniques used by priest doctors to restore altered appearances to normality. The upper echelons of Egyptian society placed great importance on appearance, and this seems to have been the stimulus for development of modern-day plastic surgery. From a beginning of simply reducing fractures and transferring local skin, plastic surgery today encompasses free-tissue transfers and microvascular surgery, allowing great strides in the ability to restore not only appearance but function as well.1
In patients with cancer, the goals of reconstructive surgery are to allow for adequate resection of tumor with clear margins, facilitate initiation of adjuvant therapy, maximize quality of life by improving function and esthetics, and minimize donor site complications. Therefore, considerations for timing and type of reconstruction include patient age, sex, and body habitus; tumor stage and prognosis; functional status of patient; available donor sites; and psychosocial state. The patient defect should be matched with the most appropriate reconstructive methods. Part 1 of this article will focus on breast reconstruction surgery.
Breast reconstruction In 2007, only 29.3% of patients in California undergoing mastectomy had reconstructions. Insurance status (public), race (African American), and hospital type (community) are all significant limiting factors.2 Surgical options for breast reconstruction include the use of tissue expanders, implants, and autologous tissue. Reconstruction can be done at the time of the mastectomy or after completion of cancer treatment. The goal is to produce symmetry by matching the remaining breast in contour, dimension, and position. Even the best reconstruction, however, cannot replace the natural breast.
In general, implant-based reconstructions require less surgery initially but have limitations and are not always trouble free. Quality of long-term results is directly related to implant tolerability. The esthetic results from autologous reconstruction are considered superior because of their versatility, more natural appearance, and durability.They can also better withstand radiotherapy.3
Contraindications to breast reconstruction include uncontrolled and nonresectable chest wall disease, rapidly progressing systemic disease, serious comorbidity, and psychological instability. Relative contraindications are smoking and obesity (body mass index >30-35). The National Comp rehensive Cancer Network guidelines state that “Smoking increases the risk of complications for all types of re construction… patients should be made aware of the increased rates of wound healing complications and partial or complete flap failure among smokers."4
The best cosmetic result is achieved with a skin-sparing mastectomy (SSM). This procedure takes only the skin that must be removed to prevent cancer recurrence: the nipple, areola, and biopsy sites. The incision is smaller, and the resulting skin tone is more even. Evidence suggests that the risk of local and regional recurrence with SSM is equivalent to that with traditional mastectomy when performed by an experienced breast surgeon.4 Some surgeons are performing nipple-areolar complex (NAC)-sparing mastectomies, but current data are insufficient to support their use in oncologic surgery.4 Nipple function is not salvaged in these procedures.
Tissue expansion/implant reconstruction In this simple method of reconstruction, an inflatable silicone balloon (the expander) is placed in a submuscular pocket deep to the pectoralis major muscle. The expander is only partially inflated when inserted to allow safe closure of the overlying muscle and skin. It is expanded by a series of postoperative saline injections. The “fills” start 1 to 4 weeks postoperatively and are done every 1 to 2 weeks until the desired size is reached. Reconstruction can be done in a one-stage surgery if a combination volume expander–implant is placed. Most surgeons, however, believe that a better cosmetic result is achieved if the tissue expander is replaced by a permanent implant in a second outpatient procedure. Alternatively, surgeons may be able to insert a fixed-volume implant without an expander in some small-breasted women. Acellular dermal matrix (ADM) can be used to support expanders or implants, which allows more volume to be instilled at the time of mastectomy. This process allows some patients to bypass the use of an expander and others to receive fewer fills.5,6
Operating time for the initial surgery is short, approximately 1 hour. Hospital stay is between 1 and 3 days. Candidates for this type of reconstruction are women with small nonptotic breasts; those having bilateral reconstruction; those who will accept a mastoplexy procedure on the opposite breast if necessary; those who desire minimal scarring; and those unable to tolerate extensive surgery. Contraindications include chest wall tissues that are thin or damaged, radical mastectomy, and extensive infraclavicular tissue deformity. The main complications are capsular contraction, implant rupture, and wound infections. Recovery time is generally 4 to 6 weeks.7,8
The US Food and Drug Ad min - istration has approved four breast im - plants. Two of these are silicone implants that were approved in 2006 for breast reconstruction in women of any age. All other silicone im plants, including the more cohesive “gummy bear” implants, are considered investigational devices, and women must be enrolled in a clinical trial to receive them.7
Postoperatively, patients will have one or two drains and moderate pain, fatigue, and discomfort. Each surgeon has his or her individual preferences, but generally patients are told not to lift more than 5 lb for 4 weeks and not to raise the arm above the shoulder or reach straight out to the side for 1 to 2 weeks. It is also important for patients to know that they should not undergo magnetic resonance imaging while the expander is in place because in most devices the ports are metal.
Autologous reconstruction Musculocutaneous flaps, which consist of a segment of vascularized muscle with the overlying skin and fat, form the foundation for autologous reconstructions (Figure). In pedicle flaps, the vascular origin remains intact, so a microvascular surgeon is not required for the procedure. Two types of pedicle flaps are used in breast reconstruction. The latissimus dorsi (LD) flap contains the thoracodorsal artery and vein and is tunneled under the axilla to create a breast mound. It may be combined with an implant to create a larger breast. The transverse rectus abdominis myocutaneous (TRAM) pedicle flap contains the entire rectus muscle and the superior epigastric artery and vein. It is tunneled under the skin and subcutaneous tissue of the diaphragm.9,10
Free flaps require a microvascular surgeon. This flap is harvested along with its blood supply. The flap’s artery and vein are then anastomosed to local vessels in the breast by microvascular techniques. Less muscle is used, resulting in less donor site morbidity (hernias, bulging, abdominal weakness). Although a free TRAM flap is the most common, the transverse upper gracilis free flap is another option.
Skilled microvascular reconstructive surgeons are now performing perforator flaps. These flaps harvest the blood vessels that traverse the muscle and perforate the fascia to supply the skin and fat above it. No muscle is removed. Perforator flaps can use the deep inferior epigastric perforator (DIEP) artery, the superficial inferior epigastric artery, the superior gluteal artery, and the inferior gluteal artery. Stacked DIEP flaps can be used to create a very large breast mound.11,12
Operating time for these surgeries is 4 to 8 hours per breast. Perforator flaps take the most time. Hospitalization is usually 3 days with an LD flap and 4 to 5 days with the other flaps. Candidates are women who desire a breast mound with a more natural appearance and texture; want to match a large ptotic breast; have sufficient donor tissue; and are healthy enough to tolerate a longer operating time and a more strenuous recovery. Contraindications include lack of trained nursing staff to monitor for vessel thrombosis, previous liposuction or surgery to donor site, active smoking (within 1 month), and, possibly, diabetes and obesity. Major complications include flap loss (2%-3% for high-volume surgeons), flap necrosis, abdominal hernia, and infections. Recovery time is generally 6 to 8 weeks.5,8,11,12
Postoperatively, it is important to check the flaps for perfusion (Table).13,14 Free flaps require hourly checks initially, whereas pedicle flaps can be checked every 4 hours. Patients having abdominal flaps are kept in a flexed position postoperatively to prevent strain on the abdominal incision. This position plus surgical tightening of the abdominal wall may result in diaphragmatic restriction and the potential for ineffective gas exchange, making pulmonary toilet very important. Adequate hydration is necessary to ensure adequate perfusion of the flap. If the patient becomes hypotensive, fluid boluses, not vasopressors, should be used. Tightness, pulling, numbness in abdominal and rib cage areas, and back pain are common complaints in addition to postoperative mastectomy pain.9,15
NAC reconstruction NAC reconstruction leads to increased patient satisfaction with the results. It is usually a secondary procedure performed 2 to 3 months after the initial surgery. This allows time for the swelling to subside and the breast mound to “settle.” The nipple is reconstructed first. Nipple placement is extremely important in producing a satisfying outcome.
Nipple reconstruction is most commonly accomplished by a local flap. The surgeon elevates one or two flaps of skin and fat from the breast mound to create a projecting hub. The donor sites are generally closed by suturing the opposing edges together. A major problem can be loss of projection over time, so some surgeons will use an ADM injection or a piece of rib to maintain projection over time.5,8
The reconstructed nipple needs to be protected and supported for about 2 weeks. A standard maternity plastic nipple shield, a plastic medicine cup, or the last inch of a 10-mL syringe can be secured with tape over the nipple to protect it.
Areola reconstruction can be done via a full-thickness skin graft. However, this is painful and expensive. Excellent results are obtained today by tattooing, because of the wide variety of pigments available. This quick and simple process has minimal morbidity. In fact, it has been reported that in a skilled tattoo artist’s hands, a 3-dimensional NAC can be created.
Summary Breast reconstruction can maximize quality of life for patients who have undergone mastectomy. The patient and the healthcare team has numerous options for reconstruction, which can improve appearance, increase functional ability, and enhance patient well-being.
References
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