Options in Breast Reconstruction

Diagnosis of breast cancer is the greatest shock for any woman. A never-ending train of thoughts runs through your head – “I never thought it would happen to me”, “Has it spread?”, “Do I need chemo?”, “Will I lose my breast?”, and so on… Please take a deep breath and try to take everything one step at a time. Your breast surgeon will see you and explain your diagnosis and surgical options. You will then be referred to a plastic and reconstructive surgeon to discuss breast reconstruction options best suited for you. This is a wonderful opportunity for your fears of losing your breast to be alleviated. Remember that every patient is unique, and surgical and reconstructive options that were offered to your acquaintance may not be suitable for you. Spend time with your reconstructive surgeon and discuss the options suitable for you. Make a list of questions to discuss in the consultation – see “Five important questions to ask your Reconstructive Surgeon”.

Immediate breast reconstruction at the time of tumor removal is currently the standard of care. Apart from the obvious psychological benefits, there are also technical advantages of preserving the skin envelope of the breast and possibly the nipple and areola, which produces a superior aesthetic result.

Various options are available and the choice of procedure is tailored to the type, location and biology of cancer and specific patient’s preferences and desires.

Here is a brief overview of common reconstructive options.

Reconstruction following Lumpectomy
Lumpectomy entails removal of the tumor with a margin of surrounding healthy tissue. Radiation is always indicated in case of lumpectomy to prevent tumor recurrence. The resultant defect needs to be filled to avoid breast deformity, which may be exacerbated by radiation.

Local Parenchymal flaps
This procedure entails repositioning the breast tissue (parenchyma) to fill the post-lumpectomy defect. It is reserved for patients with moderate breast size and small tumors located in the upper outer quadrant of the breast. Opposite side matching procedure is usually not performed. The drawbacks of this technique include scarring and possible breast distortion following radiation. There may also be a size discrepancy between the two breasts.

Therapeutic Mammaplasty
This procedure entails reshaping breast tissue to fill the lumpectomy defect and doing a lift and/or reduction at the same time. Opposite side matching procedure is performed simultaneously to ensure breast symmetry. It is a very versatile technique that allows reconstruction of tumors in any location in the breast. Depending on the size of the breasts, it may be possible to reconstruct defects following removal of large amount of tissue. This technique also relieves the discomfort associated with large breasts. The scars and appearance of the breasts following this procedure are the same as after a breast reduction or lift. Performing a breast lift assists in limiting the radiation field, which otherwise may need to extend to the abdomen in large pendulous breasts.

Reconstruction following Mastectomy
Mastectomy entails removal of breast tissue. Recently, skin sparing and nipple sparing mastectomies combined with immediate reconstruction gained popularity. Preserving the skin envelope of the breasts and nipple areola complex allows for pleasing and natural aesthetic results. Following skin and/or nipple sparing mastectomy it is possible to fill the skin envelope with either implants or the patient’s own tissue.

Implant reconstruction
Ideal candidates for reconstruction with implants are ladies with small to medium size breasts that are not droopy, and who do not require radiation therapy. The operation entails filling the breast skin envelope with implants which are placed underneath the pectoral muscles. Advantages of implant based reconstruction are that the patient can choose the size and shape of the breasts; the result retains shape well and has the “augmented” look which some women find aesthetically pleasing. Disadvantages include device failure (leak, rupture), capsular contracture (reconstructed breast becoming hard, distorted and/or painful), rippling and implant visibility, animation (implants moving when pectoral muscles contract) and a very rare type of lymphoma (implant associated anaplastic large cell lymphoma).

Reconstruction with patient’s own tissue:

Goldilocks procedure
Goldilocks procedure was described in 2012 in Atlanta, USA. It entails using the skin flaps of the breasts to re-create a new breast mound following skin sparing mastectomy. It presents a reliable option with no donor site morbidity, i.e. losing or scarring a muscle. It may be used for reconstruction of one or both breasts. The procedure has since been modified and is currently used post nipple sparing mastectomy. Ideal candidates are ladies with large pendulous breasts. In ladies with small or moderate sized breasts additional tissue from loco-regional flaps around the breasts may be used to add volume. There may be some contour irregularities in reconstructed breasts, which may be corrected at a later stage with fat fills. The nipples and areolae may become congested, which may in turn result in partial or total nipple areolar loss.

Goldilocks and Thoracoepigastric flaps
In ladies with small to medium size breasts who desire skin/nipple sparing mastectomy and Goldilocks reconstruction, but do not have sufficient skin excess in the breasts to create an adequate breast mound, additional tissue may be imported in a form of thoraco-epigastric flap. This regional flap is composed of skin and subcutaneous fatty tissue of the upper abdomen getting blood supply from small blood vessels in the inframammary crease. The flap is folded up to form the new breast mound and the abdominal skin is pulled up and secured in the inframammary crease.

Latissimus Dorsi flap
This muscle flap has been considered a “workhorse” flap for breast and chest wall reconstruction for over a century. It incorporates the latissimus dorsi muscle with or without overlying skin. Its blood supply comes from the axilla and conveniently allows it to be transposed from the back to the anterior chest. It can provide a small sized reconstruction (average muscle weight is 150g) which is resistant to deleterious effects of radiation. Its biggest disadvantage is the sacrifice of a muscle that moves the shoulder. For about six months following the procedure the patient may experience a degree of weakness in the same arm. However, as the remaining muscle groups get stronger they gradually take over the function of the latissimus muscle. Other disadvantages include the need to reposition the patient during surgery to allow harvest and insetting of the muscle, possibility of fluid collections (seromas) at the donor site and an additional scar on the back.

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