DESPITE ADVANCES IN BOTH early detection and treatment, the incidence of breast
cancer is increasing. This disease strikes one in nine women in the United States during
their lifetime. The American Cancer Society estimated that 182,000 new cases of breast
cancer would be diagnosed in 1993 and that 46,000 women would die from this disease.
[1]
Women for whom surgery is the recommended treatment for their breast cancer will
undergo either a lumpectomy or a mastectomy. [2] These
women are faced with both a potentially lethal disease and the loss of a socially prized
organ. [3] Breast reconstruction can help women cope with the
resulting anxieties and adjust to their new lifestyle.
This article reviews the decision-making process, timing considerations, and breast
reconstruction options available today.
There is no standard period of time between mastectomy and reconstruction that can be
considered ideal for all patients. Central to all decisions concerning the timing, type, and
extent of breast reconstruction is the goal of providing the best-possible management of
the cancer itself. [7] With respect to time, there are two
categories of reconstruction: immediate and delayed.
Immediate Reconstruction
Immediate reconstruction occurs during the same operative procedure as does the
mastectomy. This option is especially appropriate for patients with stage I breast cancer.
The advantages of immediate reconstruction are that the patient experiences only one
operation, one anesthesia application, and one hospital stay, as reconstruction
of the nipple and areola can be done on an outpatient basis.
Women with stage II and III breast cancer are also candidates for immediate
reconstruction, since evidence has shown that reconstruction does not prolong healing,
does not delay or postpone initiation of chemotherapy or radiation, does not alter
recurrence or survival rates, and does not affect the frequency of recurrent disease. [3,8-
11] Studies have also shown that patients who have undergone immediate breast
reconstruction experience less anxiety, depression, sexual dysfunction, and body image
problems. [12-15]
TABLE 1: Critical Factors That Influence Decision Making Regarding Breast
Reconstruction
FACTOR RESULT RESOURCES
ACCESS TO INFORMATION Inhibits decision - Photographs of
- Lack of widespread, finished results
quality-controlled - Volunteer patients
information - ACS, NCI pamphlets
- ACS slide program on
breast reconstruction
ECONOMIC CONCERNS
- High variability/expense Inhibits decision - Letter from physician
- Question of - Written agreement from
cost-effectiveness insurance company
preoperatively
- Research hospital
MEDICAL CONDITION(S)
- Stage of disease Inhibits decision - Delay in scheduling
- Obesity reconstruction until
- Diabetes condition(s) under
- Hypertension control
- Smoking
- Irradiation
INTRAPSYCHIC PERSPECTIVES
- Against reconstruction Inhibits decision - Professional counseling
* Fear of additional surgery and support
* Fear of cancer recurrence - Discussion of
* Belief it is "not necessary" reconstruction options
* Martyred syndrome with significant others
* Superfunctioning - Information on breast
- For reconstruction reconstruction
* Elimination of external - Consultations prior
prosthesis to mastectomy
* Need to feel whole again
* Restoration of symmetry
* Increase in self-confidence
* Maintenanc of feelings of
feminine attractiveness
INTERPERSONAL/TRANSITIONAL IMPACT
- Spouse or lover Inhibits or promotes - Information on breast
- Mother, daughter decision reconstruction prior
- Breast surgeon to mastectomy
- Plastic surgeon - Consultations prior to
mastectomy
Delayed Reconstruction
Delayed reconstruction is performed after the mastectomy wound heals. In the 1980s,
breast reconstruction was usually performed after mastectomy 2 to 3 months after
adjuvant therapy ended, which resulted in a 6 to 9-month delay. [7] Reconstruction was also delayed when women were not
emotionally prepared to make the decision at the time of the mastectomy, they were not
fully informed of their options, or there was inadequate time to prepare properly (eg,
autogenous blood donation). [2] These reasons remain true
today.
Reconstruction Options
Women seek breast reconstruction with hopes of creating a symmetrical, natural-looking
breast mound. Thanks to the urgings of breast cancer patients, general surgeons have
developed less ablative surgical treatments for breast cancer, and plastic and
reconstructive surgeons have developed new techniques for breast reconstruction. [7,16]
Breast reconstruction can be accomplished as a prosthetic implant, tissue expansion, or
flap procedure. Together, surgeon and patient select the method that meets the patient's
needs with minimum complications.
Although the woman who seeks breast reconstruction may theoretically be eligible for a
variety of procedures, many factors must be considered in determining which method is
most appropriate. A discussion of some of these factors, including the patient's medical
history, surgical techniques, complications, and the advantages and disadvantages of each
reconstruction option follows.
Figure 1
Silicone Breast Implant Under Muscle and Skin
Adapted from Knobf et al, [18] with permission.
Implant-Dependent Techniques
These techniques are especially appropriate for women whose opposite breast is small to
moderate in size and has minimal ptosis. The most common method of breast
reconstruction-breast implants-involves the use of available tissue and the placement of a
silicone or saline prosthesis after a total mastectomy.
[15-17]
The prosthesis is implanted under the musculofascial layer of the chest wall
(Fig 1).
Because the tight tissues of the mastectomy site are gradually stretched by the implant,
the final result is not achieved until several months after implant placement.
[7]
The incidence of capsular contracture has decreased since surgeons began placing the
silicone implant beneath the musculofascial layer rather than under the subcutaneous
tissues.[17] Also, the polyurethane-covered (textured) silicone
implants are less likely to cause contracture. [2,6,16,19,20]
The following complications, which are being investigated by the FDA, can occur with
silicone implants:
- capsular contracture
- gel bleed
- implant breakage, rupture, and retrieval
- allergies and rare forms of autoimmune diseases (such as lupus erythematosus and
scleroderma)
- asymmetry
- dislocation
With the exception of capsular contracture, which occurs with an average of 35% of
silicone implants, quantification of these alleged complications has not been well
established. [3] However, patients should be alerted to the
possibility of problems such as infection, leakage, or rupture of the implant; persistent or
prolonged joint
pain; extreme asymmetry or dislodging of the prosthesis; and hardness or discoloration
around the implant. If any of these problems are observed, the patient should consult her
reconstructive surgeon, who should make the necessary report to the Product Problem
Reporting Program (PPRP: 1-800-638-6725). [3]
Tissue Expansion
Breast reconstruction utilizing a tissue expander is best suited to women with a larger,
more ptotic opposite breast. It is also indicated for women who have medical problems
that prohibit reconstruction with autogenous tissue.
[2]
Contraindications for using a tissue expander are radical mastectomy, extremely tight
chest wall skin, and an irradiated chest wall.
[2,
21,22]
After most modified radical mastectomies, the remaining skin flaps are soft and supple
and have no skin excess. Tissue expansion is often performed at this point. Tissue
expansion applies the principle of gradual stretching of the chest wall to obtain enough
cover for a silicone breast implant that is larger than one that could be positioned during
the initial operation, and that reduces tightness and subsequent firmness of the chest wall
against the implant.

Figure 2
Round 700cm^3 Tissue Expander With Remote Port-a Design Commonly Used for
Breast Reconstruction.
In this procedure, an empty silicone bag or "balloon"
(Fig 2) is placed either
subcutaneously or submuscularly. About 1 to 2 weeks postoperatively, after the
mastectomy wound has healed, the tissue expander is slowly inflated with saline solution
during weekly outpatient visits. In order to achieve ptosis of a normal breast, the
expander is filled about 200 mL beyond the volume of the opposite breast and kept
overfilled for several months until the tissues can accommodate their expanded condition
(Fig 3).
Figure 3
Immediate Breast Reconstruction Patient Undergoing Temporary Overexpansion
Figure 4
Same Patient as in Figure 3, After Completion of Reconstruction
During a second operation, the tissue expander is replaced with a permanent silicone
breast implant that is symmetrical with the opposite breast. If necessary for symmetry,
mastopexy or other surgical alteration of the opposite breast can also be performed at that
time [19] (Fig 4).
Recently, a permanent tissue expander and implant that eliminates the need for a second
operation has been developed. After the desired size and position of the breast are
achieved, the fill valve is removed, and the device becomes a permanent, double-lumen
silicone breast implant. [7,23]
The great advantage of tissue expansion is that it permits breast reconstruction without
the need for distant flaps, which simplifies reconstruction and minimizes scarring.
Disadvantages, though slight, do exist. One is the amount of time the procedure involves.
The entire process, from tissue expansion to nipple/areola reconstruction, can take 4 to 6
months to complete. Patients often require ongoing emotional support during this time.
The possibility of complications poses another disadvantage. [24,25] Capsular contraction, implant rupture, and periprosthetic
infection may necessitate the removal or replacement of the implant. [2,7,19]
Flap Procedures
Flap procedures offer breast cancer patients a third reconstruction option. Three methods
are available: the transverse rectus abdominis myocutaneous (TRAM) method, the
latissimus dorsi method (LDM), and the gluteal free flap method. Each method has
distinct indications and contraindications, as discussed below.
TRAM FLAP.--The TRAM flap, an autogenous tissue reconstruction, can be offered to
most women who request it. The only significant
contraindications are uncontrolled cancer, diabetes, extreme obesity, or other severe
medical problems that would make elective surgery unwise. [19] The TRAM flap is especially indicated in the following
instances:
- salvage of the breast and chest wall
- reconstruction after modified radical mastectomy
- reconstruction after bilateral mastectomy
- reconstruction after subcutaneous mastectomy for patients with silicone intolerance [2]
Candidates for the TRAM flap must be selected carefully and critically, however, to avoid
serious complications. Cigarette smokers should abstain from smoking 3 to 4 weeks
preoperatively and 1 to 2 weeks postoperatively to decrease the risk of necrosis in the newly
transferred tissue. [7,16] Known as the
"rummy tuck," this procedure involves the removal of skin and fat from the lower abdomen
in a transverse dimension. The donor site is then closed primarily, with a resulting low-
transverse abdominal scar (Figs 5, 6).
Figure 5
Preoperative Plan Showing Location of Donor site for TRAM Flap.
Figure 6
Result of TRAM Flap Reconstruction
There are two types of TRAM flaps: the conventional TRAM and the free TRAM. With the
conventional TRAM procedure, the superior epigastric artery and vein and the entire length
of one (sometimes two) rectus abdominis muscle(s) are used to transfer abdominal tissues as
a myocutaneous pedicled flap to form a breast mound via an epigastric tunnel. In the free
TRAM procedure, the larger vessels of the inferior epigastric artery and vein are used. With
the free TRAM flap, the blood supply does not need to travel the entire length of the rectus
abdominis muscle. [26] The tissue is completely detached from the abdomen and reattached
to the chest with the blood supply reconnected to the blood vessels in the axilla. [19]
One advantage to the TRAM flap is that it does not require a silicone implant. Another
advantage is that the result is a naturally soft breast in a shape and size adjusted for ptosis
and symmetry. Also, the scar is easily hidden. Disadvantages of the TRAM include the fact
that it involves a highly technical procedure that requires 3 to 4 hours of surgery, a 4 to 5-
day hospital stay, and an average of 2 to 3 months for recovery. The TRAM procedure is
also very expensive.
Complications include necrosis of a significant part of the flap and the risk of flap ischemia,
which is higher in patients who smoke and in obese patients. Use of the double-pedicle flap
(procedure utilizing two rectus muscles instead of one) and free flap techniques has
improved the survival of the TRAM flap. Fortunately, the most significant abdominal
complications, bulging and hernia, can usually be corrected with further surgery. [19]
LDM FLAP.--The LDM flap is selected when there is a skin deficit that can be
corrected with the transportation of large amounts of skin, fat, and muscle to the chest wall
area. The LDM procedure transports a segment of skin from the upper back to the anterior
chest (Fig 7)i.
Figure 7 Donor Site
Plan for LDM Reconstruction
Women who are not candidates for the TRAM flap are the most frequent candidates for the
LDM flap. Tight or irradiated skin, marked obesity, and smoking history are other
indications for this procedure. [7,19]
When this procedure was initially done, it corrected for the shortage of skin created by the
mastectomy but did not provide enough tissue volume to simulate a breast mound, which
had to be achieved later with a silicone implant [19]
(Fig 8).
Figure 8 Result of
Breast Reconstruction with LDM Flap.
A
recent study described a process that involved the recruitment of overlying fat
transferred with the latissimus dorsi muscle, such that the new breast can be
reconstructed without an implant. [2]
The LDM flap is planned on the back to include the appropriate amounts of skin and
muscle to replace missing tissues and permit the introduction of a silicone implant
beneath it to give the proper size and shape to the reconstructed breast.
Although a complex operation, this procedure is reliable, with only a 2% rate of partial
loss of the flap. [7] Some complications have occurred,
however. The implant itself has developed firmness or distortion from capsule
contracture in 25% to 30% of the patients. [19] Also, patients
may complain about having a scar on their back or report that the loss of muscle from the
side causes tightness.
GLUTEAL FREE FLAP.--When other flap techniques are not appropriate, the
breast can be reconstructed with fat and skin from the buttocks. [2,7,9,24]
This option is known as the gluteal free flap. The appropriate tissue needed for this breast
reconstruction, along with a segment of the gluteus maximus muscle, is elevated on the
vascular pedicle. The internal mammary artery or axillary vessels are prepared, and the
buttocks tissue is then transferred via a microvascular technique and anastomosed to the
internal mammary artery. [27]
Figure 9
Donor Site Plan for Superior Gluteal Free Flap Breast Reconstruction
Figure 10
Result of a Superior Free Flap Breast Reconstruction
The advantages of the superior gluteal free flap (Figs 9, 10) procedure are that a breast
implant is not required, and the donor scar can be hidden at the fold of the buttocks area.
Also, the procedure is less painful and recovery is less prolonged than with the TRAM
flap procedure. [7] However, the gluteal free flap procedure is
technically difficult, expensive, time-consuming, and has a significantly higher failure
rate than does the TRAM flap. [19]
Nipple-Areola Reconstruction
Although not mandatory, reconstruction of the nipple-areola complex puts the finishing
touch on the breast mound, leaving women with more natural looking breasts. [24] Regardless of which breast reconstruction is used, nipple-
areola reconstruction (Fig 11) has been successfully accomplished with a wide variety of
techniques. Earlier nipple reconstruction often used tissue taken from an opposite large
nipple. [7] New procedures enable the reconstruction of the
nipple with tissues available at the skin site of the new nipple. [28,29] The pigmentation match for the nipple-areola is achieved
by selecting a darker skin color from the color chart to allow for fading, and using an
intradermal tattoo technique that is performed by nurses in an outpatient setting. [30]
Conclusions
Breast reconstruction is a valuable option in the total treatment and management of breast
cancer. It is imperative that physicians and nurses be well informed of the reconstruction
methods available. Taking into account each woman's physical and psychological profile,
as well as other interpersonal factors, is also essential. Once assessed, the patient and
family can be educated and resources can be mobilized in order that a timely and
appropriate decision regarding breast reconstruction options can be made.
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Acknowledgement.--The author would like to thank Stephen S. Kroll, MD, for the use of
Figures 2-10.