Breast reconstruction

A brief description of breast reconstruction for plastic surgery residents

1. BREAST RECONSTRUCTION DR G SWAMY VIVEK SENIOR RESIDENT DEPT OF PLASTIC SURGERY GMCH, GUWAHATI

2. PROSTHETIC TECHNIQUES

3. PATIENT SELECTION The ideal candidate for breast reconstruction with prosthetic implants is a thin patient with bilateral reconstruction, or a thin patient with a normal, non ptotic breast who requires unilateral reconstruction. The patient is educated that the goal is to achieve as much symmetry as possible, but that this may only be accomplished when she is in her brassiere and clothing. For patients with obesity, broad chest wall and multiple medical problems, an implant-based reconstruction may be more efficient than an autologous tissue reconstruction.

4. However, implant-based reconstructions may require more than one operation and may require revisions over time. Additionally, if the patient has a chronic respiratory illness, the pressure from the tissue expander on the chest wall during the expansion process may exacerbate that underlying condition. Finally, prosthetic-based breast reconstruction often requires multiple steps and multiple visits to the office.

5. It is also important to explain to patients that prosthetic breast reconstruction does not hinder detection of local or regional recurrence.

6. TIMING Breast reconstruction using prosthetic techniques can be accomplished either in the immediate or delayed setting. ln the setting of a single-stage breast reconstruction using a permanent implant, immediate reconstruction allows for the placement of an optimally sized device. Delayed breast reconstruction using a prosthetic technique is also possible; however, tissue expansion is almost always necessary. In the setting of high-risk disease and patients who require chemotherapy and radiation therapy, a delayed reconstruction may be appropriate as it will not delay the initiation of adjuvant treatment.

7. TECHNIQUE With all types of breast reconstruction, the primary goal is to achieve a breast mound that is as symmetrical as possible with the other breast or to the contralateral reconstruction in the setting of bilateral mastectomies. Ideally, mastectomy incisions are planned to minimize their impact on subsequent tissue expansion and their visibility in conventional clothing. the site of the inframammary fold should be marked and preserved whenever possible. At the conclusion of the mastectomy, if the inframammary fold has been detached, it should be repaired.

8. Expanders can be placed in a complete submuscular or subfascial pocket by elevating the medial border of the serratus anterior muscle and/or fascia and elevating the pectoralis major from lateral to medial and bringing both the subserratus and subpectoral pocket into communication at the level of or slightly below the inframammary fold. Final coverage of the expander occurs by suturing the lateral border of the pectoralis major muscle to the serratus anterior muscle. An alternative to using the serratus anterior muscle and/or fascia for total submuscular coverage of the tissue expander is to use acellular dermal matrix.

9. Once a subpectoral pocket is created for the expander, a sheet of acellular dermal matrix is tailored to the defect. It is placed in the inferior and lateral portions of the expander pocket and sutured to the pectoralis major muscle superiorly and to the chest wall or inframammary fold inferiorly.

10. EXPANDERS Choosing the appropriate expander is based on several factors, including breast volume, breast dimensions (height, width, and projection), breast shape, and the patient's body habitus. In general, an anatomically designed, textured surface, integrated valve tissue expander is preferred. The expander comes in various heights, widths, and amounts of projection that either can be compared with the contralateral breast or can be matched to another expander if a bilateral procedure is performed.

11. Final considerations in choosing an expander include the amount and quality of remaining breast skin after the mastectomy and the impact of planned contralateral symmetry procedures (augmentation, mastopexy, and reduction} on the shape of the opposite breast. The expander typically comes partially filled with air. The air is evacuated from the expander and a small amount of saline solution is infiltrated into the expander to confirm the functioning of the port.

12. DELAYED TISSUE EXPANDERS Typically, the mastectomy scar is excised and the mastectomy flaps are re-elevated, although not to the extent as was necessary during the original mastectomy. Once adequate pectoralis muscle is exposed, either the lateral border of the pectoralis muscle is identified and elevated from the chest wall, or the muscle is split in the direction of the muscle fibers and a subpectoralis major pocket is created. Similar to immediate expander placement, care is taken to avoid elevation of the pectoralis minor muscle.

13. It is critical to free any scar tissue that will restrict expansion of the mastectomy flaps. The expander is placed such that the zone of maximum expansion is located in the lower pole of the reconstructed breast, allowing for preferential expansion of the lower pole, for a more natural shape of the reconstructed breast. Acellular dermal matrix may also be used for delayed reconstruction.

14. EXPANSION Intraoperatively, the tissue expander is filled to a volume that optimally obliterates dead space, but does not impart excessive pressure on the mastectomy skin flaps. Because blood supply to the newly created mastectomy skin flap may be tenuous, overfilling the expander intraoperatively can impede circulation. closed suction drainage tubes left at the time of expander placement are removed when output is <30 mL per 24 hours, which typically occurs within 2 weeks. Tissue expansion begins in the office approximately 10 to 14 days after surgery. A magnetic device is used to identify the site of the integrated fill valve under the patient's skin.

15. The area is cleansed with an antiseptic solution and a butterfly needle is used to gain access to the tissue expander. Approximately 30 to 120 mL of saline is injected into the expander during each expansion session. Expansion sessions can occur as frequently as once per week or as infrequently as once per month, there is no set criterion to the expansion schedule. The final goal of the expansion is to achieve a volume that is approximately 25% to 30% greater the expander volume. This allows for extra skin to be available at the exchange procedure, which can be used to create maximum breast ptosis and inferior pole projection. Overexpansion also allows for the removal of unsightly mastectomy scars, or scars that have resulted from delayed or poor wound healing.

16. Patients can be safely expanded during chemotherapy, although it may be necessary to coordinate the expansion schedule with their chemotherapy schedule. Final replacement of the expander to a permanent implant is deferred until the patient's blood counts have returned to normal after the conclusion of chemotherapy. Also after simulation for radiotherapy, it is important not to adjust the expander volume. In general, soft tissues are allowed to rest for at least 1 month between the time of the last expansion and the time of the exchange procedure.

17. EXCHANGE OF TISSUE EXPANDER FOR PERAMANENT IMPLANT The goals of the exchange procedure are to create a breast mound that has similar shape, volume, and position as the contralateral breast in a unilateral reconstruction, and to maximize symmetry and position in a bilateral reconstruction. The second stage in breast reconstruction using a prosthetic device involves exchanging the tissue expander to a permanent implant. Typically, patients will wait at least 1 month following the last expansion before undergoing the exchange procedure. If the patient received chemotherapy as part of her management, then at least 3 to 4 weeks after the last chemotherapy session is allowed to pass so that bone marrow suppression induced by chemotherapy can resolve before undergoing an elective surgical procedure.

18. The patient is positioned in the operating room such that the reconstruction can be accomplished in the sitting position, allowing for maximum ptosis of the natural breast. The permanent implant can then be placed with maximum symmetry. The type and shape of the device is selected preoperatively.

19. The selection of the proper final implant is aided by measuring the dimensions of the normal breast. Various techniques facilitate this process. (1) comparing the weight of breast removed at the time of mastectomy to the volume of the tissue expander. This will help in approximating the mass and volume needed for reconstruction. (2) is to partially empty the expander prior to removing expander. The expander is emptied to the point where its volume approximates the contralateral breast.

20. The volume of the remaining fluid in the expander, the base dimension of the pocket from which the expander came, and the height and projection of contralateral breast determine the appropriate size and shape of the implant.

21. Perhaps, the most important step in placement of the permanent implant for breast reconstruction is accurate positioning of the inframammary fold. Depending on the degree of ptosis and whether a contralateral symmetry procedure will be performed on the opposite breast, the marking will help determine the final location of the inframammary fold. In general, the position of the inframammary fold of the reconstruction should match the normal side or contralateral side even in the setting of a bilateral reconstruction.

22. In the setting of a more ptotic breast, where the breast gland descends below the level of the inframammary fold, it may be desirable to place the bottom of the implant at the level of the bottom of the breast on the natural side. In this circumstance, the inframammary fold on the reconstructed side may be slightly lower than it is on the contralateral side; however, the overall position of the breast mounds is similar.

23. MULTIPLE TECHNIQUES FOR RECREATING THE INFRAMAMMARY FOLD: Internal placement of capsulorraphy sutures External marionette sutures Liposuction of the inframammary fold to allow the external skin to stick to the chest wall. Advancement of upper abdominal skin flap, suturing this internally to the chest wall to define the fold.

24. Maximizing projection of the reconstructed breast can be further accomplished by performing internal capsulotomies positioned either circumferentially, radially or both or by performing a capsulectomy. An inferior pole capsulectomy or capsulotomy will allow for maximizing inferior pole projection and ptosis in the reconstructed breast. If patient desires contralateral symmetry procedure ( augmentation mammoplasty, mastopexy, or reduction mammoplasty), this is typically accomplished at the time of exchange of tissue expander with permanent implant.

25. BREAST RECONSTRUCTION WITH IMMEDIATE PLACEMENT OF AN IMPLANT In select cases, immediate breast reconstruction can be accomplished with placement of an implant. The mastectomy skin flaps must be completely healthy, the pocket must be of adequate size so as to insert an implant of the appropriate size, and the appropriate implant must be selected. Acellular dermal matrix may be beneficial in single-stage reconstruction. The disadvantage of immediate reconstruction includes the risk of asymmetry with the contralateral breast, inadequate size and projection of the device, and the potential need for a revision to improve the quality of the overall reconstruction.

26. In general, use of a two staged reconstruction with a tissue expander placed at the first stage, followed by a permanent implant at the second stage, maximizes the surgeon's control. Whenever reconstruction in a single stage is performed with an implant, patients should be made aware that there may be a need for a revisionary procedure to improve the overall result.

27. BREAST RECONSTRUCTION AFTER NIPPLE-SPARING MASTETOMY

28. POST OPERATIVE CARE After placement of a tissue expander, or after exchange of an expander for a permanent implant, the patient is placed in a surgical bra, which helps to hold dressings in place and provides a place for drains to be fastened. The use of oral antibiotics after surgery is discretionary. The use of a conforming breast binder to hold the implant position may be advantageous. Patients are instructed to avoid the use of an underwire bra for several weeks after surgery and. depending on the type of implant used, may be instructed to massage their implants. Implant massage is usually reserved for patients with smooth implants rather than shaped, anatomic implants where massage may lead to implant malposition. Pain medication is prescribed as needed

29. COMPLICATIONS Bleeding in the immediate postoperative period resulting in hematoma warrants reexploration . Hematomas under the mastectomy skin flap and around the tissue expander or permanent implant increase the risk of infection and predispose to capsular contracture. Infections typically present as cellulitis of the skin flaps over the implant. Occasionally, an abscess is identified.

30. Another early complication includes mastectomy skin flap necrosis. Superficial- or partial-thickness flap necrosis is usually managed conservatively with local wound care. Occasionally, small areas of full-thickness necrosis can also be managed with local wound care, particularly if the expander is in a complete submuscular location, thus having an interface of normal healthy tissue between the device and the area of skin necrosis.

31. LATE COMPLICATIONS: Asymmetry, Implant wrinkling Implant malposition Implant deflation Capsular contracture and infection

32. Fat grafting can be used to improve many of the contour deformities that result from mastectomy and implant reconstruction. The fat is injected in multiple different layers and feathered over the area that needs to be corrected. Some authors use acellular dermal matrix to correct rippling as well as capsular contracture.

33. IMPACT OF RADIATION ON PROSTHETIC RECONSTRUCTION Radiation therapy, whether it is delivered preoperatively or postoperatively, complicates breast reconstruction. With respect to preoperative radiation therapy, placement of a tissue expander at the time of the mastectomy may lead to failed expansion, poor expansion with lack of projection, poor wound healing and an inability to achieving the desired result from this method of reconstruction.

34. An approach to the previously irradiated patient with the use of a tissue expander is immediate placement of a latissimus dorsi myocutaneous transposition flap over the expander. The latissimus flap will have not been previously irradiated and thus is much more likely to expand without resistance. Additionally, the autologous tissue provided by the latissimus flap will increase the volume of skin for the breast reconstruction, thus enabling the reconstruction to have more projection and ptosis. In patients who require postoperative radiation therapy, radiating the permanent implant leads to a higher incidence of capsular contracture and need for revision.

35. AUTOLOGOUS TISSUE TRANSFER FOR BREAST RECONSTRUCTION

36. PEDICLED FLAP RECONSTRUCTION LATISSIMUS DORSI FLAP RECTUS ABDOMINIS FLAP

37. LATISSIMUS DORSI FLAP

38. RECTUS ABDOMINIS FLAP

39. FREE FLAPS FOR BREAST RECONSTRUCTION ABDOMINAL FREE FLAPS GLUTEAL FREE FLAP GRACILIS FREE FLAP

40. RECIPIENT AREA DISSECTION FOR FREE FLAP RECONSTRUCTION

41. ABDOMINAL FREE FLAPS

42. GLUTEAL FREE FLAP

43. GRACILIS FREE FLAP

44. NIPPLE RECONSTRUCTION Nipple reconstruction is an essential component in the creation of an attractive breast. Nipple reconstruction techniques may seem minor in the overall scheme of breast reconstruction; they are a major factor in the final result and demand meticulous attention to achieve good aesthetic results. The goal of nipple-areolar reconstruction is to create nipples that are appropriately located on the breast mound and are of appropriate size, shape, color, and texture.

45. MARKING The surgeon uses aesthetic judgment to position the nipple. One way to approximate the nipple-areola position is to cover the contralateral breast and carefully study the reconstructed breast mound and place a mark where the nipple location appears appropriate. The contralateral breast is then uncovered and a careful comparison is made. Adjustments are made as deemed necessary. The patient is allowed to have input into the nipple-areola location as well. A round adhesive bandage is placed on this location. The patient can relocate the bandage to what she feels is an appropriate location. In bilateral reconstructions, there is more latitude in nipple location yet the marking methods are similar. Initially, each breast is assessed separately. Careful inspection of both breasts is then performed and adjustments/compromises made as necessary.

46. METHODS LOCAL FLAPS GRAFTS DONATED (HOMOGRAFT) CARTILAGE NIPPLE-AREOLA TATTOOING

47. LOCAL FLAPS Local flaps are the most frequently performed methods of nipple reconstruction today. A central dermal fat pedicle is wrapped by full- or partial-thickness skin flaps, creating a nipple. Examples of the commonly used pedicle flaps are the skate flap, modified skate flap, star flap, cervical visor (CV) flap, wrap flap, and fishtail flap.

48. SKATE FLAP

49. STAR FLAP

50. CV FLAP

51. CERVICAL VISOR FLAP

52. One must keep in mind that these are second-generation flaps; that is, they are created from flaps of tissue that were themselves either mastectomy flaps or autologous transferred flaps. These methods may not be suitable for reconstructions in patients with thin skin or irradiated tissue. Local flaps are best suited for breast mounds composed of autologous tissue where these soft-tissue requirements are met. These local flaps often lose volume and contract substantially over time. Consequently, an initial overcorrection is warranted.

53. In unilateral reconstruction, the local flap is made 50% to 75% larger than the contralateral nipple size in anticipation of atrophy. If the final result is substantially larger than desired, a reduction is readily performed as an office procedure.

54. GRAFTS Grafts are particularly useful in prosthetic reconstructions as there is often a paucity of soft tissue to create nipples with sufficient projection using the local flap techniques. The disadvantage of autografts is that they require a donor site. Grafts of tongue, earlobe, toe, and labia have been used, but these donor sites are undesirable and are of mostly historical significance. One of the best methods in unilateral breast reconstruction is a composite nipple graft from the contralateral nipple. If the patient has sufficient projection in the contralateral nipple and is willing to use it as a donor site, excellent nipple symmetry can be attained. This is an easy technique to perform and can readily be accomplished in the office. The patient must be informed that the donor nipple may suffer loss of sensibility and erectile and ductile function.

55. COMBINED MODIFIED CV FLAP WITH CONTRALATERAL COMPOSITE NIPPLE GRAFT

56. The donor site is dressed with antibiotic ointment and a bandage. The graft dressings are changed 1 week postoperatively, and are dressed every other day with Xeroform for an additional week. Although the graft may appear dark and dusky after 1 week, it is usually pink and viable within 2 to 3 weeks. Over the next 2 to 3 months, the graft may grow approximately 20% to 30% larger, attaining the appearance of the contralateral nipple.

57. SKIN GRAFTS Skin grafts can be used to create the nipple-areola complex, often using an ellipse of medial thigh skin. The graft is placed over the de-epithelialized, circular, donor site and sutured with a tie-over dressing that is removed 1 week postoperatively. A separate, central graft is placed to simulate the nipple. Alternately, the skin graft is placed around a local flap or composite graft. These grafts, however, are poor color matches to "normal" areolae.

58. DONATED (HOMOGRAFT) CARTILAGE The use of cartilage is an excellent method of nipple reconstruction, particularly in prosthetic reconstruction where there might be a soft-tissue deficiency. The surgeon has complete control over the dimensions of the nipple. The procedure is applicable to both unilateral and bilateral nipple reconstruction, is an easy procedure to perform, does not involve a donor site, and maintains long-lasting projection. A disadvantage of donated cartilage is that the resulting nipple is with an unnatural reel. If the grafts are placed too superficially and do not have a smooth contour. they can extrude through the skin, necessitating revision and/or removal.

59. ACELLULAR DERMIS MATTRICES Processed dermis can be used as an adjunct to local flap reconstruction or as the primary material for the nipple. A cylindrical roll of ACM can be created and placed in front of the dermal fat pedicle of any local flap. This creates a more rigid "strut" which is then wrapped by the lateral skin flaps. The dimensions of this strut can be precisely controlled to achieve the desired dimensions of the nipple. The surgeon must pay careful attention when designing the dimensions of the lateral flaps in order to accommodate the added volume of the ACM strut.

60. ACELLULAR DERMAL MATRIX

61. NIPPLE AREOLA TATTOOING Nipple-areola tattooing is an excellent adjuvant treatment. Because color choice is unlimited, excellent symmetry is attainable in both unilateral and bilateral reconstructions. With attention to detail, excellent three-dimensional appearance can be created with the use of basic light and shading principles. The Montgomery glands can also be added to achieve a more natural appearance. Tattooing should be performed approximately 6 to 8 weeks after nipple reconstruction, to allow for wounds to heal.

62. This is particularly useful in patients with prosthetic reconstructions who have thin, tenuous skin that would not support a local flap or graft. Tattoos often fade and approximately 60% of patients may require a secondary tattoo session. If the nipple reconstruction is not possible in the patient then entire nipple areola can be created tattooing in 3 dimension.

63. SECONDARY CASES In cases where a reconstructed nipple has insufficient dimensions and there is disparity with the contralateral nipple, secondary procedures can be performed. Small asymmetries can be rectified with the insertion of a small dermal graft, ACM, or cartilage into the base of a local flap. A skin or composite graft can be placed on top or around a portion of the flap or graft. Autologous fat can be injected into the base of a local flap as well. For more significant disparities involving local flaps, a second flap can be raised using the base of the previous flap as the new nipple location. A CV or fishtail flap is particularly useful in this situation. The use of long-term injectable fillers can be used to supplement smaller nipple deficits.

64. INJECTABLE FILLERS The use of injectable fillers can be used to create a new nipple as well as augment or improve the contours of an established nipple. Dermal substitutes can also be utilized for this as well. Fillers are easily injected in the office. We raise a wheal in the skin using the base of a 3 cc syringe that is spilt on the side to accommodate the needle. The syringe helps contain the filler within the confines of the nipple location. We inject 0.3 to O.5 cc per session and repeat it every 3 to 6 months to build sufficient projection. Does not have enough evidence.

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