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Breast Reconstruction

Breast reconstruction can be done immediately during mastectomy or delayed after adjuvant therapy completion. Immediate reconstruction provides better cosmetic outcomes and early psychological benefits, while delayed allows more time for consideration and ensures therapy is done. Techniques include expanders/implants, latissimus dorsi flaps, TRAM/DIEP flaps, and fat grafting. Each option has pros and cons like operating time, recovery duration, and risks of complications or donor site morbidity that require considering patient factors and desires. A multidisciplinary team can help personalize the optimal reconstructive approach.

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Breast reconstructionBreast reconstruction Penny L McManus FRCSPenny L McManus FRCS Consultant oncoplastic breast surgeonConsultant oncoplastic breast surgeon Hull UKHull UK
Breast ReconstructionBreast Reconstruction  Immediate (with mastectomy)Immediate (with mastectomy)  Better cosmetic outcomesBetter cosmetic outcomes  CheaperCheaper  Early Psychological benefitEarly Psychological benefit  DelayedDelayed  Patient has more time to consider optionsPatient has more time to consider options  Adjuvant therapy completedAdjuvant therapy completed  Higher long term patient satisfaction ratesHigher long term patient satisfaction rates
Skin sparing mastectomy for immediate reconstructionSkin sparing mastectomy for immediate reconstruction
Techniques in BreastTechniques in Breast ReconstructionReconstruction  Expander/ImplantExpander/Implant  Latissimus Dorsi (LD)Latissimus Dorsi (LD)  TRAM / DIEPTRAM / DIEP  Other free flaps – SGAP, IGAP, TUGOther free flaps – SGAP, IGAP, TUG  lipomodelinglipomodeling
Implant ReconstructionImplant Reconstruction  2 stage:2 stage:  Tissue expander then permanent siliconTissue expander then permanent silicon implantimplant  1 stage:1 stage:  Permanent expander-implantPermanent expander-implant  Permanent implant with dermal sling orPermanent implant with dermal sling or Acellular dermal matrixAcellular dermal matrix
2 stage implant reconstruction2 stage implant reconstruction  Delayed and immediateDelayed and immediate  Submuscular tissueSubmuscular tissue expanderexpander  Serial expansionSerial expansion  Change to permanentChange to permanent silicone implantsilicone implant
Tissue expander placed in submuscular pocketTissue expander placed in submuscular pocket
Delayed 2 stage implant reconstructionDelayed 2 stage implant reconstruction
AAdvantagesdvantages  Short operating timeShort operating time and recoveryand recovery  Low complication rateLow complication rate  No donor siteNo donor site morbiditymorbidity  Normal appearance inNormal appearance in clothingclothing
DDisadvantagesisadvantages  2 operations2 operations  No ptosisNo ptosis  No change with bodyNo change with body weight/ageweight/age  Feels coldFeels cold  Late complicationsLate complications RadiotherapyRadiotherapy
Immediate implant with dermal slingImmediate implant with dermal sling  Wise pattern mastectomyWise pattern mastectomy  Lower pole skin de-Lower pole skin de- epithelialised & sutured toepithelialised & sutured to lower edge pectoralislower edge pectoralis  Ptotic breastsPtotic breasts  Patients requestingPatients requesting reductionreduction  Risk reductionRisk reduction mastectomymastectomy
Immediate implant with dermal slingImmediate implant with dermal sling
Immediate implant with acellular dermalImmediate implant with acellular dermal matrixmatrix  Strattice, Alloderm,Strattice, Alloderm, Permacol, SurgimendPermacol, Surgimend  Sutured to lower edgeSutured to lower edge pectoralis andpectoralis and inframammary foldinframammary fold  Smaller, non-ptoticSmaller, non-ptotic breastbreast  High complications rateHigh complications rate  High costHigh cost
Immediate implant with ADMImmediate implant with ADM
ComplicationsComplications  EarlyEarly  Wound breakdownWound breakdown  InfectionInfection  explantationexplantation  RotationRotation  LateLate  Capsular contracture (20% at 10 years)Capsular contracture (20% at 10 years)  Deterioration of overlying tissuesDeterioration of overlying tissues  Implant ruptureImplant rupture
Patient selectionPatient selection  Patient desires & expectationsPatient desires & expectations  Small, non-ptotic breastSmall, non-ptotic breast  Contralateral reduction or mastopexyContralateral reduction or mastopexy  Avoid in diabetics, smokers, steroids, RTAvoid in diabetics, smokers, steroids, RT
Latissimus Dorsi Flap
Extended Latissimus Dorsi flapExtended Latissimus Dorsi flap
Extended LD flapExtended LD flap
Pros and ConsPros and Cons  Operating time 4-5Operating time 4-5 hourshours  Stay 4 daysStay 4 days  Recovery 4-5 weekRecovery 4-5 week  Safe and reliable flapSafe and reliable flap  Can be irradiated ifCan be irradiated if autologousautologous  Donor site scar andDonor site scar and morbiditymorbidity  TwitchingTwitching  SeromaSeroma  Flap failureFlap failure  Flap atrophyFlap atrophy
LD with implantLD with implant Preop immediate LD + Implant 2 years postop Preop delayed LD + Implant 2 years postop
Autologous LDAutologous LD Preop immediate LD 3 months postop Preop delayed LD 12 months postop
Autologous LD & fat transferAutologous LD & fat transfer Pre-op 5 years post-op Pre-op 2 years post-op
TRAM/DIEPTRAM/DIEP FlapsFlaps  Anterior abdominal wall tissueAnterior abdominal wall tissue  PedicledPedicled  Transverse Rectus Abdominis MyocutaneousTransverse Rectus Abdominis Myocutaneous (TRAM) Flap(TRAM) Flap  Free:Free:  Free TRAMFree TRAM  Deep Inferior Epigastric Perforator (DIEP) FlapDeep Inferior Epigastric Perforator (DIEP) Flap  SIEA flapSIEA flap  Operating time 6-8 hoursOperating time 6-8 hours  Stay 4-5 daysStay 4-5 days  Recovery 7-8 weeksRecovery 7-8 weeks
Pros and ConsPros and Cons  Larger reconstructionLarger reconstruction  Muscle sparingMuscle sparing  Natural feel &Natural feel & consistencyconsistency  ““tummy tuck”tummy tuck”  longer operating timelonger operating time  higher risk of flap losshigher risk of flap loss  donor site morbiditydonor site morbidity  donor site scardonor site scar
Fat graftingFat grafting  Autologous fat transfer / LipomodelingAutologous fat transfer / Lipomodeling  Fat removed by liposuction from areas of excessFat removed by liposuction from areas of excess  Centrifuged in theatre to remove blood and deadCentrifuged in theatre to remove blood and dead cellscells  Injected into breastInjected into breast  Can be used with other types of reconstructionCan be used with other types of reconstruction  Can be used to correct defects after breastCan be used to correct defects after breast conserving surgery or failed reconstructionconserving surgery or failed reconstruction  Low morbidityLow morbidity
Fat transferFat transfer
Fat transfer to revise reconstructionFat transfer to revise reconstruction
Fat transfer for asymmetryFat transfer for asymmetry
Fat transfer for breast conserving surgery defectFat transfer for breast conserving surgery defect
Fat transfer alone for reconstructionFat transfer alone for reconstruction
SummarySummary  Reconstruction benefits patientsReconstruction benefits patients  Wide range of optionsWide range of options  Patient selection is keyPatient selection is key  ““Reconstructive ladder”Reconstructive ladder”
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