Breast Reconstruction

Following Mastectomy:
Indications,
Techniques, and
Results
Hakim K. Said, MD, FACS, Sara H. Javid, MD,
Shannon Colohan, MD, Otway Louie, MD,
David W. Mathes, MD, Benjamin O. Anderson, MD,
and Peter C. Neligan, MD

arly treatment of breast cancer centered on removal of disease,

prevention of recurrence, and life expectancy. Since then, early
detection and multimodal treatment have proven very effective, and
breast cancer is currently one of the most curable forms of cancer.
Survival without breast restoration, however, has a dramatic negative
impact on self-image and lifestyle. Advances in the quality of care
have focused on quality of life after treatment, particularly on returning women to their former lives before they were diagnosed with
cancer. Today, the options for restoring a breast are better than ever,
with natural tissues, organic matrices, or synthetic implants, especially when used in novel combinations.

INDICATIONS
The surgical treatment options for both noninvasive (ductal carcinoma in situ) and invasive breast cancer include breast-conserving
surgery (lumpectomy) and mastectomy. Approximately 70% of
patients with early-stage invasive breast cancer are candidates for and
elect breast-conserving surgery, but many will require or choose mastectomy due to the extent of malignant disease in the breast, prior
radiotherapy exposure, contraindication to or desire to avoid radiotherapy, and/or risk reduction for subsequent breast cancers. Various
technical approaches to mastectomy differ primarily with respect to
the amount of the skin envelope that is preserved.
A nonskin-sparing (standard) mastectomy is performed when
a patient does not desire or cannot undergo immediate reconstruction. A wide elliptical incision is made, excising the nipple areolar
complex (NAC) and the skin overlying the tumor, ultimately leading
to a long transverse or oblique scar. The goal should be to minimize
postoperative skin redundancy that might interfere with the wearing

of a prosthesis. In contrast, in a skin-sparing mastectomy, the breast

is removed through a much smaller circumareolar incision narrowly
encompassing the NAC in order to preserve the skin envelope for the
reconstructed breast mound. A newer variation of this skin-sparing
approach is the nipple-sparing, or total skin-sparing, mastectomy.
The nipple-sparing mastectomy, previously termed the subcutaneous
mastectomy in the 1970s and 1980s, was an operation that fell into
disrepute out of concern that excessive fibroglandular tissue would
be left behind the NAC, but it is now being reevaluated for the
purpose of cancer prophylaxis and in carefully selected breast cancer
cases.
Because the perfusion to the skin and the nipple comes primarily
from the breast that must be removed, the remaining skin may be
relatively ischemic and prone to healing challenges. As the mastectomy plane grows closer to the skin, the chance increases of causing
damage to the subdermal plexus that is the only remaining source of
perfusion. Whereas in a standard mastectomy, this ischemic central
breast skin would be removed, in skin-sparing mastectomy, most of
these skin flaps are preserved. Nipple-sparing mastectomy leaves
essentially all the breast skin intact, regardless of how far away the
nearest intact blood vessels lie. This further increases the amount of
ischemic skin, the chance of healing problems, and the risk of complications after either of these kinds of mastectomy. Reliably preserving an intact and undamaged subdermal plexus is a challenge in
skin-sparing mastectomy, and critically important in nipple-sparing
mastectomy, in order to avoid complications after mastectomy.
Moreover, while leaving fibroglandular tissue behind poses an oncologic risk, excessively thinning the dermal subcutaneous tissue negatively impacts the appearance and quality of the reconstructive
outcome.
In general, both skin-sparing and nipple-sparing mastectomies
are only performed in the setting of breast reconstruction, whether
that reconstruction is performed during the same operation or
shortly thereafter as a separate procedure once the skin has recovered
and the surgical pathology results are known.
Several studies have demonstrated that post-mastectomy breast
reconstruction affords several benefits, including improved body
image, psychological health, and reduced concern for cancer recurrence. Although most patients are eligible to undergo reconstruction
in a delayed fashion following completion of their breast cancer
treatment, many patients are eligible to begin reconstruction at the
time of their mastectomy (immediate reconstruction). The decision to proceed with immediate reconstruction depends on patient
and disease factors, as well as treatment-related factors. In some cases,
the mastectomy is performed as a separate procedure, with reconstruction to be performed a few weeks later (delayed-immediate),
in order to allow pathologic examination of the specimen before
proceeding with the reconstructive procedure.
Immediate reconstruction, with either a prosthetic device or
autologous tissue, requires a preserved skin envelope with a skinsparing mastectomy. The majority of patients with early-stage
(0, I, II) breast cancer can undergo this approach. Immediate

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Breast Reconstruction Following Mastectomy: Indications, Techniques, and Results

reconstruction is contraindicated in a patient with skin involvement,

such as skin ulceration (T4b) or inflammatory (T4d) breast cancer.
In addition, if a patient is expected to require post-mastectomy radiation therapy (PMRT), such as those with locally advanced (stage III)
cancers, immediate reconstruction with autologous tissue is to be
avoided to prevent the deleterious effects of radiation on the reconstruction. However, in such cases, skin-sparing mastectomy with
immediate reconstruction using a temporary prosthesis (tissue
expander) is often possible, with the understanding that this expander
may need to be deflated prior to radiation. Other relative contraindications for immediate reconstruction include active smoking
history and medical comorbidities such as morbid obesity or cardiopulmonary disease.

RECONSTRUCTIVE TECHNIQUES
Women who elect to undergo reconstruction have two main reconstructive options: prosthetic devices (tissue expanders, implants) or
autologous tissue reconstruction using tissue transferred from a
distant donor site to the chest wall. The choice can sometimes be
driven by the breast cancer treatment plan, such as patients who will
require PMRT, which largely eliminates the option of immediate
autologous reconstruction. More commonly, reconstruction reflects
the patients choice and the reconstructive surgeons recommendation. For instance, very slender women may not have ample donor
tissue available for autologous reconstruction, and women with a
history of prior radiation (e.g., mantle radiation for lymphoma) may
not be candidates for implant-based reconstruction because of the
significantly higher risk of implant complications in a radiated
setting.

FIGURE 1 Implant reconstruction.

Implants are selected by many women because of the desire to avoid

a second surgical scar and recovery associated with the donor site or
because it entails less extensive surgery. Downsides of implant-based
reconstruction include higher risk of infection due to presence of a
foreign body, risk of capsular contracture, and risk of leak or rupture,
which would require removal or replacement.

mastectomy to permit construction of a full breast of the desired size.

Second, the mastectomy skin must be of sufficient viability to tolerate
the weight and expansion produced by a full-size implant. Third, the
patients desired goals in terms of the final implant must be explicitly
known and achievable at this point. Many patients lose enough skin
through mastectomy to reduce the volume that can be reached, or
they have delicate skin flaps that would be compromised by or even
necrose as a result of excessive tension from a full-size implant.
Patients generally are better served by placement of an adjustable
expander with a lower fill volume and a two-stage reconstruction. In
addition, the second stage implant exchange allows the patient to
choose her desired implant size and type and allows for another
chance to adjust the pocket for a more optimal breast shape.

Two Stages

Tissue Matrices

Historically, the two-stage implant approach is the earliest form of

breast reconstruction, although implants have gone through many
iterations. Today the great majority of implants are placed in two
stages. First, an adjustable implant called an expander is placed subpectorally, either deflated or partially filled. Typically, over the next 3
months, the expander is inflated with saline on a weekly basis to reach
an appropriate goal size. At that point, the expander is replaced by a
softer and more aesthetic implant, saline or silicone. Although in the
United States, between 1994 and 2007, a moratorium prohibited use
of silicone gel implants, elsewhere in the world their use has continued. In 2007, the safety data were convincing enough to warrant
rerelease of silicone gel implants on the U.S. market. Subsequent
studies have documented significantly improved patient satisfaction
and better aesthetic outcomes in the setting of breast reconstruction
using silicone gel implants versus saline implants. Most patients currently choose the silicone implants, and the outcomes are closer to
the results obtained with autologous reconstruction (Figure 1).

Offered by a number of manufacturers, tissue matrices are organic

substrates derived from human, porcine, or bovine origins, processed
to produce an implantable organic scaffold. They are commonly
placed in conjunction with an expander at the time of mastectomy
as a sling, which offloads the skin by bearing the weight of the
implant. In addition, these matrices allow a significant degree of
control over the size and shape of the implant pocket, including
definitive positioning of the inframammary fold. Evidence suggests
they may have a beneficial effect on capsular contracture rates, which
are especially high among patients who have undergone radiation
(Figure 2).

Implants

One Stage
An alternative to this approach is one-stage reconstruction using a
permanent silicone implant placed subpectorally at the time of the
mastectomy. This reduces the number of surgeries required but poses
several risks. First, there must be sufficient skin redundancy after

Autologous Methods of Breast Reconstruction

Some women do not like the idea of having implants, while others,
for any number of reasons, may not be candidates for that type of
reconstruction. The most common reason that a patient may not be
eligible for implant reconstruction is because of a history of radiation. Using the patients own tissues to reconstruct the entire breast
is an attractive option for these patients. Natural tissue has the potential to provide durable reconstruction of the full breast volume, often
without the vulnerability of implants, which can fail or require
replacement eventually.

THE B REAST

623

FIGURE 2 One-stage implant

reconstruction with tissue matrix.

There are many ways to reconstruct a breast using autologous

tissue. All involve incisions for harvesting tissues from various donor
sites elsewhere on the body. These methods can be divided into three
broad categories: (1) fat grafting, (2) pedicled flap reconstruction,
and (3) free flap reconstruction. The last of these requires microsurgical skills.
Fat Grafting
The use of fat grafting in breast reconstruction is a relatively new
technique. Fat grafting has been used in aesthetic surgery for a
number of years. Structural fat grafting involves harvesting adipose
tissue from other areas on the body through a series of tiny nick
incisions. Small amounts of fat are carefully prepared and then
injected in multiple planes into areas to be treated. Depending on the
site, 30% to 70% of the fat injected with this technique can be
retained and engrafted long-term. Overcorrection, subsidence, and
retreatment are the keys to reaching the goal size with this method.
It is an extremely useful technique for reconstruction of lumpectomy
defects, where one treatment may be all that is necessary (Petit et al.,
2011).
It has also gained favor for contour correction and volume adjustment in conjunction with implant reconstruction. Some of the issues
associated with implants, such as implant rippling or edge step-off
deformities, can be addressed easily with lipofilling using fat harvested from other sites of redundancy, without significant scars or
deformity at the donor sites.
More recently, Khouri has introduced the concept of external
expansion using a suction cup device worn by women called the
Brava bra (BRAVA LLC, Miami, Fla). This expands the recipient site,
creating an edematous mound that can accommodate larger volumes
of fat injection. Typically, patients will undergo 3 to 4 sessions of fat
grafting over a number of months, in conjunction with a regimen of
external expansion before and after each surgery. With persistence,
the entire breast mound can be reconstructed to a reasonable volume
with repeated rounds of this method.
Pedicled Flap Reconstruction
A pedicled flap is one in which the vascular supply remains intact
and is transferred into the breast from an adjacent region. The two
most common pedicled flaps in use for breast reconstruction are the
latissimus dorsi myocutaneous flap and the transverse rectus abdominis myocutaneous (TRAM) flap. Other flaps exist based on perforators from the thoracodorsal vessels and the intercostal vessels. These
will be discussed later. Many of these flaps are also extremely useful
for reconstructing partial mastectomy defects or defects resulting
from lumpectomy.
The Latissimus Flap
The blood supply of the latissimus dorsi is from the thoracodorsal
artery. Because of the favorable position of this pedicle, the latissimus
muscle and its overlying skin can be pivoted on the pedicle and

rotated from the back to the chest. The skin paddle of the latissimus
can be oriented obliquely or transversely to hide the donor site scar
under the bra line. In most cases, the latissimus flap is combined with
placement of a breast implant, as there usually is insufficient bulk to
create a breast mound. This is particularly useful in patients who have
been through radiation treatments. The addition of nonradiated
tissue from the back can make implant reconstruction possible in
patients who otherwise might not be candidates for implants.
The TRAM Flap
Introduced by Hartrampf, the TRAM flap takes advantage of the
blood supply of the abdominal skin. Based on the superior epigastric
artery, an ellipse of lower abdominal skin and fat, along with underlying rectus abdominis muscle, is mobilized. This flap is tunneled from
the abdomen into the chest, where it is folded and inset to reproduce
the breast shape. The abdominal donor site is treated similarly to a
tummy tuck, by undermining the upper abdominal skin and advancing it to facilitate closure. Critics of the pedicled TRAM flap point
out that, with sacrifice of one or both rectus muscles, there is significant potential weakening of the abdominal wall and careful reconstruction of the abdomen to prevent future development of a ventral
hernia is critical.
Free Flap Breast Reconstruction
Free flap breast reconstruction has undergone an evolution over the
past 20 years. Because of concerns with abdominal wall integrity
following pedicled TRAM flap reconstruction, the free TRAM was
developed, based on the deep inferior epigastric vessels. The rationale
was that less muscle could be harvested, and the expectation was that
donor morbidity would be less. As our knowledge of vascular
anatomy improved, the free TRAM became the muscle-sparing free
TRAM, harvesting less and less muscle. Ultimately, with the introduction of perforator flaps, we learned how to dissect the vascular
pedicle out of the rectus muscle with minimal disruption of the
muscle and preservation of the segmental nerves. This evolved to
become the deep inferior epigastric perforator (DIEP) flap (Figure
3). In each of these flaps, the major pedicle, the deep inferior epigastric artery, is divided and reanastomosed in the chest to the internal
mammary vessels.
In patients who are not candidates for abdominal-flap breast
reconstruction, either because of insufficient tissue availability or
because of previous surgery, there are several other options. These
include the transverse upper gracilis (TUG) flap (Figure 4), which
includes skin and subcutaneous fat from the upper inner thigh, or
the superior and inferior gluteal artery perforator (SGAP and IGAP)
flaps. Each relies on a donor site and removal of excess tissue at a
respective site on the patient. All of these flaps require advanced
microsurgical expertise as well as an intimate knowledge of the vascular anatomy of the flap involved based on preoperative computed
tomographic scan imaging evaluation. Each donor site also represents a particular set of benefits or drawbacks depending on the site
and the patient.

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Breast Reconstruction Following Mastectomy: Indications, Techniques, and Results

FIGURE 3 Immediate deep inferior epigastric perforator (DIEP) flap reconstruction.

FIGURE 4 Delayed transverse upper gracilis (TAG) flap reconstruction.

Suggested Readings
Boneti C, Yuen J, Santiago C, et al: Oncologic safety of nipple skin-sparing or
total skin-sparing mastectomies with immediate reconstruction, J Am Coll
Surg 212(4):686693; discussion 693685, 2011.
Khouri RK, Eisenmann-Klein M, et al: Brava and autologous fat transfer is a
safe and effective breast augmentation alternative: results of a 6-year,
81-patient, prospective multicenter study, Plast Reconstr Surg 129(5):1173
1187, 2012.
Lambert K, Mokbel K: Does post-mastectomy radiotherapy represent a contraindication to skin-sparing mastectomy and immediate reconstruction:
an update, Surg Oncol 21(2):e67e74, 2012.
Laronga C, Lewis JD, Smith PD: The changing face of mastectomy: an oncologic and cosmetic perspective, Cancer Control 19(4):286294, 2012.

Petit JY, Lohsiriwat V, Clough KB, et al: The oncologic outcome and immediate surgical complications of lipofilling in breast cancer patients: a multicenter studyMilan-Paris-Lyon experience of 646 lipofilling procedures,
Plast Reconstr Surg 128(2):341346, 2011.
Salzberg CA: Focus on technique: one-stage implant-based breast reconstruction, Plast Reconstr Surg 130(5 Suppl 2):95S103S, 2012.
Wagner JL, Fearmonti R, Hunt KK, et al: Prospective evaluation of the nippleareola complex sparing mastectomy for risk reduction and for early-stage
breast cancer, Ann Surg Oncol 19(4):11371144, 2012.
Warren Peled A, Foster RD, Stover AC, et al: Outcomes after total skin-sparing
mastectomy and immediate reconstruction in 657 breasts, Ann Surg Oncol
19(11):34023409, 2012.