BREAST RECONSTRUCTION SURGERY OVERVIEW

Breast reconstruction is associated with high levels of quality of life and patient satisfaction, but can be a complicated endeavor and may require several surgeries over time.  There are many approaches and options and the choice of reconstructive technique involves careful consideration of your goals, medical issues, anatomy, and comprehensive cancer treatment plan.  The below descriptions are provided without bias only as a basic introduction to the broad topic which your surgeon will describe further. 

Types of breast cancer surgery.  The type of surgery you have to remove the cancer and any additional treatment will be largely decided upon by your breast surgeon in conjunction with a hospital Tumor Board which is a group of doctors/providers with different specialties.  This group regularly meets to review patient data and circumstances to help determine the best possible cancer treatment and care plan for an individual patient.  In general, there are two types of breast cancer surgeries which can be further subdivided:

1. Lumpectomy.  More formally called breast conservation therapy, this approach may also be referred to as partial mastectomy, segmental resection, segmentectomy, wide local excision, and central mastectomy among others and the portion removed may or may not include the nipple and areola.   The incision and resulting scar is frequently located directly over or adjacent to the location of the tumor.  At times, the scar can be ‘hidden’ along the border of the areola or can be incorporated into a breast reduction or breast lift scar pattern.   Most patients undergoing breast conservation therapy will be treated with radiation following lumpectomy.
2. Mastectomy.  This is the removal of all breast tissue and is often subdivided into the following:
   1. Skin-sparing mastectomy.  All the breast tissue including the nipple and areola is removed with preservation of the majority of the overlying skin envelope
   2. Nipple-sparing mastectomy.  Essentially the same as a skin-sparing mastectomy but the nipple and areola are preserved and the scar can be less prominent.

Timing of reconstruction.  The timing of reconstruction can be influenced by many factors including chemotherapy and radiation but in general we describe the temporal approach to reconstruction as:

1. No reconstruction.  Not every patient is a candidate for breast reconstruction and not every patient chooses to pursue reconstruction.  We discuss contraindications to reconstruction below.
2. Delayed reconstruction.  Some patients pursue reconstruction weeks, months, or even years after their mastectomy or partial mastectomy.  The reason for the delay may be due to the evolving patient perspective or improvement in the patient’s overall health status which now permits reconstruction.  Delayed reconstruction can also describe the effort to re-start breast reconstruction if the patient experiences failure of their initial reconstruction due to complications like infection.
3. Immediate Reconstruction.  Reconstruction is undertaken immediately after the breast surgeon removes the cancer, while the patient is still under anesthesia. 

Contraindications to Reconstruction.  Unfortunately, not every patient can be offered reconstruction if chronic medical conditions are sub-optimally controlled.  Medical conditions with increased risk of complications and reconstructive failure include smoking, morbid obesity, severe lung disease, and diabetes. 

Types of reconstruction.  The decision for what type of breast reconstruction you may be offered and decide upon is in part dependent upon whether you have a lumpectomy or a mastectomy.  We can therefore classify reconstruction as partial or whole. 

1. Partial breast reconstruction would be employed in the context of a large lumpectomy which, without reconstruction, may lead to significant changes in breast shape, size, or nipple position.   The approach to partial breast reconstruction is sometimes called oncoplastic surgery, and the remaining tissue following removal of the tumor is re-shaped, the skin is contoured, and the nipple and areola are brought up into a more youthful position if needed.  The resulting scars are more extensive than if the lumpectomy alone is performed.  The oncoplastic approach typically treats both breasts to achieve balance through a modified reduction or lift.
   1. Breast reduction. Even more tissue is removed than required for cancer treatment to alleviate problems associated with large breasts. 
   2. Breast lift.  Minimal additional breast tissue is removed, but the skin envelope is tightened.  

The oncoplastic approach is generally not ‘needed’ in the vast majority of patients undergoing lumpectomy.  It may not be a good option for patients with small breasts.

1. Whole breast reconstruction would be employed following mastectomy to recreate the entire breast mound since all breast tissue is removed, leaving only the overlying skin and at times the nipple and areola.  Breast reconstruction following mastectomy is typically divided into two broad categories:  implants and flaps. 
   1. Implants.  Breast implants can be either silicone or saline but both are lined with a silicone shell.  Implants come in a large variety of sizes and shapes.   Implant-based surgery is faster, quicker to recover, and does not impart additional scars.  Implants are typically not life-long devices and many patients seek revision within ten years.  Implants cannot resist infection and are at risk of developing a tight scar called capsular contracture.
   2. Flaps. Flaps are composed of tissue from another anatomic location, and may consist of skin, fat, and muscle.  Most importantly, flaps must have a source of blood flow and can be thought of as a transplant from one part of the body to another.    Flap surgery is more complex, and introduces additional scars and risks, but flap tissue is alive and healthy, not previously radiated, is more resistant to infection, and ages with the patient more normally.  Flap surgeries may take up to 8 hours and require several days in the hospital.  Flap donor sites include the
      1. Abdomen.  The lower abdomen is the most commonly-used source of flap tissue.   The resulting scar is not as hidden as a cosmetic abdominoplasty.  TRAM, DIEP, and SIEA flaps differ in how the blood flow to the tissue is maintained. 
      2. Buttock.  The bottock tissue can be a good source of donor fat and skin in select patients.  The SGAP flap is the most-commonly used flap from the buttock
      3. Thigh.  The upper thigh near the groin crease can provide skin and fat to reconstruct smaller breasts.  The TUG flap is the most-commonly used flap from the thigh.
      4. Back.  The back is a good source of non-radiated but relatively thin tissue to help mostly in secondary reconstructions and is usually an insufficient source of tissue for entire breast reconstruction. The latissimus dorsi and TDAP flaps are the two most-commonly used flaps from the back.

1. 1. One-stage reconstruction.  Single stage reconstruction is performed at the time of mastectomy with a permanent implant (direct to implant reconstruction) or with a flap.  Single stage reconstruction can also be performed in a delayed manner some time after mastectomy, but would require flap reconstruction.  Delayed reconstruction with implants would require the placement of a tissue expander (see below).
   2. Two-stage reconstruction.  Traditionally referred to as two-stage reconstruction, this approach may ultimately require more than two surgeries to achieve the appropriate result.  This approach in immediate reconstruction has several benefits irrespective of the final reconstructive choice (implant or flap).  It is also utilized in delayed reconstruction in preparation for a more permanent implant or flap.  Two-stage reconstruction starts with a tissue expander
      1. Tissue expander.   This is a temporary balloon-like implant inserted in the deflated or partially deflated state.  During subsequent office visits following surgery the expander will be sequentially inflated with air or saline to stretch the overlying skin and sometimes muscle to make room for a future implant or even flap.  Benefits of expanders include:
         1. Less strain on the overlying skin.  The deflated expander does not place significant stretch on the overlying thin skin at the time of its placement following mastectomy.  The overlying skin is initially very fragile and its blood flow has been altered and reduced by removing the underlying breast.  As the skin heals and its blood supply becomes more robust, it will tolerate gradual stretch by the expander.
         2. The expander sets the position for the new breast mound including the lower breast fold and the side margin.  At the time of mastectomy, these landmarks can be distorted.
         3. Reduced operating time.  The expander reconstruction surgery is about 1-1.5 hours per breast. 
         4. No additional scars. 
         5. The tissue expander can act as a ‘place holder’ as the patient completes radiation or further considers the final reconstruction using an implant or flap

Tissue expander downsides include:

1. Additional surgery to replace the expander with an implant or flap.
2. It is fairly rigid compared to gel implants or a person’s own tissue
3. It is a large piece of foreign material that if infected needs to be removed and cannot be replaced immediately
4. Reconstructions using tissue expanders may take longer to achieve the end result

The number of considerations involved with breast reconstruction seems to never end and the journey through breast reconstruction will be a constant learning process.  In addition to above notations, it is worth knowing at least a little bit about the following points.

1. Blood flow.  Successful healing is dependent upon adequate blood flow to the remaining tissue following surgery.  Oncoplastic approaches and certainly mastectomy most dramatically alter the normal blood flow to the overlying skin or surrounding tissue.    The relatively fragile blood flow improves with time but initially may be insufficient and could lead to skin loss and breakdown, nipple loss, fat necrosis, infection, and the need for further surgery. 
2. Drains.  Drains are a critical tool in breast reconstruction to remove excess fluid produced by the body in response to the internal ‘wound’ from surgery.  They may be used for several weeks and are removed once the daily output reduces sufficiently.  Without drains or with the premature removal of a drain, excess fluid may not be re-absorbed by the body and may pool around the surgical site forming a seroma.  Seromas increase the risk of infection and failure of the reconstruction.
3. Radiation.  Most lumpectomy patients and some mastectomy patients undergo radiation for 3-6 weeks.  Although radiation in these patients is critical to reduce the risk of cancer recurrence, it does render the radiated tissue permanently more fragile.  Radiation increases the risk of capsular contracture with implants, causes the breast to be a bit smaller and more firm, and increases the risk of wound healing problems, infection, and reconstructive failure. 
4. The other breast.  It is very common to have surgery on the unaffected breast and may include a lift or mastopexy, a breast reduction, or a breast augmentation. .  Your surgeon will request insurance authorization for these balancing procedures following mastectomy or even lumpectomy.
5. Nipples.  Absent areolae and nipples can be reconstructed through surgical and/or tattoo techniques, but this step is usually last in the reconstructive process and may not be completed for up to a year following mastectomy.  In nipple-sparing mastectomies, there is still risk of nipple loss or even nipple positioning problems.
6. Fat grafting.  This is the process of capturing fat from liposuction of the belly, flanks, or sides and re-injecting it in relatively small volumes to help correct irregularities in the contour of your primary reconstruction. 
7. Implant-associated lymphoma.  This is a rare type of cancer that can develop around breast implants, and is typically associated with textured implants. 
8. Complications.  Unfortunately, complications are fairly common with breast reconstruction and range from relatively mild to more significant and potentially life-threatening.  Compilations include but are not limited to asymmetry, poor scarring, infection, flap donor site problems, flap loss, seroma, hematoma, skin breakdown, nipple loss, capsular contracture, implant-associated lymphoma and cosmetic dissatisfaction.
9. There is almost always another option.  For women who are not candidates for immediate reconstruction or who have lost their reconstruction through complications, there is almost always an opportunity for future reconstruction.