Reconstruction After Mastectomy
Reconstruction after mastectomy can be done immediately during the same procedure when the breast tissue is removed, or delayed, usually after chemotherapy and radiation has been completed. In our setting, most of our patients with newly diagnosed breast cancer undergo immediate breast reconstruction. Patients looking for advice or referred after mastectomies receive delayed breast reconstructions. There are a variety of reconstructive options available:
IMPLANT BASED RECONSTRUCTION
With implant based reconstruction, there are several possible options available depending on the type of mastectomy that was performed, the patient’s body habitus and her own personal choice:
Implant reconstruction can be performed immediately if there is sufficient skin available after the mastectomy to be able to insert a breast implant. This is commonly called direct to implant breast reconstruction. In our practice this is our preferred method in skin, nipple and areola sparing mastectomies and it can be done in combination with a reduction of the skin envelope or mastopexy procedure. We have a wide spectrum of surgical techniques available, depending on the specific patient and needs of our patients.
In a few selected cases we can perform a delayed reconstruction with a breast implant without stretching the skin with a tissue expander beforehand. This option depends on the amount, quality and elasticity of the available skin.
In many cases the skin flaps are thin after the mastectomy has been performed. This can lead to visible implants under the skin and we frequently see a condition that is called rippling. There are several options to improve the thickness, quality and appearance of the tissue covering the implant. One is to place the implant behind the pectoral muscle to cover the upper and medial part of the implant. This can in addition be combined with an acellular dermal matrix graft to keep the muscle in place and to improve tissue thickness, skin quality and appearance of the reconstructed breast.
Rippling caused by a thin skin and/or muscle cover can further be corrected at a second stage is by fat-grafting to the skin envelope to increase its thickness and reduce rippling.
We use silicone gel or saline filled implants with a silicone envelope containing it. The shape of the implants can be round or as in the majority of cases, anatomic implants mimicking the breast shape.
With expander reconstruction a tissue expander is inserted under the mastectomy skin to stretch and increase the amount of skin available until we are able to insert a permanent breast implant. This is always a two-stage procedure, except in cases where an expander is utilised that can stay inside permanently after the completion of expansion.
In the majority of cases stretching of the skin by expansion leads to capsule formation and a mild degree of contracture. The capsule is removed at the same time as the expander is removed and the permanent implant is inserted. Thus we do not recommend the routine use of a permanent expander prosthesis as a one stage procedure.
OWN TISSUE RECONSTRUCTION
Own tissue reconstruction is also called autologous reconstruction and has the advantage that there is no risk of foreign body reaction compared to implant reconstruction. No synthetic material is used for own tissue reconstruction and the end result often resembles the natural breast and is softer. There are a number of options available with own tissue reconstruction:
The DIEP flap procedure is the most frequently performed method for own tissue reconstruction in my practice. This procedure involves removing and utilizing excess fat and skin from the lower abdomen to reconstruct the breast. No muscle or fascia is sacrificed and only the blood vessels nourishing this tissue are isolated and dissected. The tissue is reshaped to adjust to the size and shape of the breast. The tissue is transplanted from the tummy to the breast by way of microsurgery, connecting the blood vessels of the abdominal tissue to vessels of the chest wall.
Removal of the tissue leaves an abdominal defect that is closed in the same way as a tummy tuck. This reconstructive procedure thus includes a cosmetic procedure to get sufficient tissue to reconstruct the resected breast tissue. The scar is located in the fold between the lower abdominal and pubic areas and stretches from one hip bone to the other as in conventional tummy tuck procedures.
FREE TRAM FLAP
The free TRAM flap is similar to the DIEP flap, except that with the free TRAM flap, part or all of the rectus muscle (abdominal muscle) is removed together with skin and fat. The reason to do a free TRAM flap is to include more blood supply if no blood vessels or so called perforators of sufficient size or caliber are identified.
The SIEA flap procedure requires no dissection of muscle to isolate blood vessels and the deep fascia is left completely intact. It is the ideal free abdominal flap but can only be performed in less than 10% of patients because the superficial abdominal blood vessels are too small for a safe micro- vascular anastomosis in more than 90% of patients. This means that microsurgical connection of these small vessels has a higher complication rate and makes the flap less reliable compared to the free TRAM and DIEP flaps. We only utilise this flap if we find sufficient calibre blood vessels during the surgical procedure.
FREE GLUTEAL FLAPS
Free gluteal flaps are an alternative in patients where the abdominal area cannot be utilised due to previous tummy tuck surgery, scarring or if there is not sufficient tissue. It is important to know is that if a patient has had a tummy tuck, no abdominal flap can be used for breast reconstruction. We can find sufficient tissue in the buttock or gluteal area in most patients. The flaps are elevated only on the perforating blood vessels and no muscle is included or sacrificed.
This procedure combines a medial thigh lift procedure with breast reconstruction surgery.
Excess skin from the medial thigh is removed with a piece of underlying gracilis muscle. This tissue is then transplanted to the chest wall. It is a good option for patients with small breasts that have excess tissue in the medial thigh area. All flap procedures until now are done with microsurgical techniques.
LATISSIMUS DORSI FLAP
The latissimus dorsi flap utilises the muscle that is located in the middle of the back and also covers the lower tip of the shoulder blade. This flap has been utilised in breast reconstruction for many years and is a versatile and reliable option. The reconstruction can be performed completely autologous or in conjunction with a breast implant. In most cases the flap does not provide sufficient volume to reconstruct the whole breast and a breast implant has to be added to get a satisfactory result. This procedure leaves a scar on the back and sacrifices a muscle that is included in the flap. Microsurgical techniques are not necessary as the flap can reach the breast on a vascular pedicle.
Fat grafting or lipofilling is a procedure where fat is taken from areas with sufficient or excess fat by special liposuction techniques. This fat is cleaned and processed. It can then be injected into areas of deficiency. The fat cells are injected in layers into the area where it is needed. This technique is commonly used to correct contour defects after the first stage of breast reconstruction or lumpectomies.
Fat grafting as a sole means of breast reconstruction after mastectomy can be performed, but it may take several procedures to build up a sufficiently sized breast. This can lead to multiple operations and visible contour defects on the areas where the fat is taken from.
STEM CELL ENRICHED FAT GRAFTING
Latest research has shown that fat or so called adipose tissue contains vast amounts of adult stem cells. Adult stem cells of fat origin have strong regenerative properties and improve and renew tissue. Utilising cell enriched fat increases fat graft take and it improves blood supply, skin quality and softness in the injected area. Up to today it has not been shown that adipose derived stem cells have any effect on cancer cells or cancer spread. I use cell enriched or stem cell enriched fat grafts in selected patients with damaged tissue caused by side effects of radiation therapy. Another indication of cell enriched fat is its use in conjunction with fat grafting to increase the amount of fat that survives after the grafting procedure.
AUTOLOGOUS RECONSTRUCTION WITH DE-EPITHELIALISED FLAPS
This technique can be applied if the patient has large breasts and wants smaller breasts after breast reconstruction. Then breast reduction methods are applied and the skin flaps of the skin that normally gets removed during breast reduction surgery are de-epithelielised and folded under the reduced breast envelope to create a new and smaller breast. It can lead to satisfactory cosmetic appearance with a less invasive surgical procedure.