Secondary procedures following autologous reconstruction

Timing of secondary procedures

In order to assess if further surgical corrective procedures are needed to the ipsilateral and contralateral breast, patients are evaluated 3 months after the initial autologous reconstruction. This time span allows the tissue to settle, and any swelling or minor fluid accumulation to subside. In this setting, the breast symmetry can be addressed more precisely. Others may prefer to perform the symmetrization during immediate reconstruction, and in doing so use the adjusted contralateral side as a model for flap shaping. It is of our opinion however, that the changes taking place postoperatively make an immediate symmetrization less predictable.

Typically, weight fluctuations take place after diagnosis of breast cancer with a trend toward weight gain in the long term. The corrective surgeries should first take place when a steady state is reached. This allows for a sustainable long-term result and reduces the risk for additional corrective procedures.

Following mastectomy and immediate reconstruction, the oncological decision for further adjuvant therapy should be rendered within 3 months. Providing that no chemotherapy or irradiation is needed, the optimal timing for secondary procedures begins at 6 months. The corrective operations are typically not carried out during chemotherapy, but rather after patients have recovered, usually 1–3 months after the last cycle. In cases needing irradiation, our approach is to wait at least 1 year after completion of the therapy before conducting surgery on the irradiated breast ( Algorithm 43.1 ). Effects of irradiation on the transferred tissue leading to poor aesthetic outcome include fibrosis, contracture and hyperpigmentation. Also, the potential for reconstruction-threatening complications tend to occur within the first year of irradiation and decreases significantly with time. In cases needing only a symmetrization of the contralateral side, the surgery can be scheduled at an earlier point in time.

There is also an additional reason for waiting with corrective procedures concerning the neo-breast. When transferring autologous tissue, the microcirculation of the flap is altered. Early refining surgeries to the flap tissue might impede flap perfusion significantly. Therefore, an interval of 6 months should pass before touching the ipsilateral side without fear of compromising flap viability.

After a first corrective procedure, a new evaluation is carried out approximately 2–3 months later. If further refinements are necessary, these can be carried out relatively quickly after stabilization and complete healing. This sequence can be continued until a satisfying result is achieved (see Algorithm 43.1 ).

Algorithm 43.1

Three months after autologous reconstruction the patients are evaluated for necessary touch-up procedures. In patients receiving adjuvant chemotherapy: second stage is planned approximately 3 months after finishing the last cycle. In patients having radiotherapy: corrections to the irradiated breast are ideally organized a year after finishing therapy, symmetrization to the contralateral side are possible earlier. In patients receiving no further treatment: refining surgery is conducted approximately 6 months after breast reconstruction. A new evaluation then takes place 2–3 months later. If further refinements are necessary, these can be carried out swiftly after complete healing. DIEP, deep inferior epigastric artery perforator; SIEA, superficial inferior epigastric artery; TMG/PAP, transverse musculocutaneous gracilis flap/profunda artery perforator; SGAP, superior gluteal artery perforator.

Treatment algorithm for secondary procedures

During patient counseling the individual wishes should be identified and addressed. In order to define the exact surgical planning, patients are asked to pinpoint three aspects which are bothering and can be tackled. These points may vary from the treating surgeons’ thoughts and ideas. Most of the time, however, patients and surgeons alike wish to accomplish best possible symmetry.

A surgical plan is developed together with the patient depending on the selected flap, clinical status and patient’s wishes. Selecting the optimal treatment strategy can be achieved after identification of the main problem(s) ( Algorithm 43.2 ). For each flap there is a slightly differing treatment algorithm, concentrating on the specific issues linked with the characteristics of transferred flap tissue and donor site ( Algorithm 43.3 ).

Algorithm 43.2

Reconstruction is evaluated after 3 months, and possible problems identified (marked green). As a next step, depending on uni- or bilateral reconstruction, further clinical assessment takes place. In unilateral cases, the neo-breast is compared with the native breast. The patient and the treating surgeon decide if the reconstructed breast is more appealing and should function as a template for the opposite side or vice versa . Depending on the chosen strategy, a surgical plan for secondary refinements is developed (marked purple). In bilateral cases, the reconstructed breast mounds are improved according to the patient’s wishes and to suit body figure. AFG, autologous fat transfer; NAC, nipple–areolar reconstruction.

Algorithm 43.3

Specific flap types tend to bring forth similar problems, which require comparable revisions: in deep inferior epigastric artery perforator/superficial inferior epigastric artery (DIEP/SIEA) flaps volume discrepancies and ptosis are common in comparison to the native breast, as are mismatches between flap volume and skin envelope. The needed revisions include a reduction of flap volume through liposuction or direct tissue excision. To reduce the skin envelope a mastopexy is inevitable. In superior gluteal artery perforator (SGAP) flaps the transition of the breast mound to the chest wall can appear sharp, necessitating a contouring and softening through autologous fat graft (AFG). In cases with an augmented appearance of the upper pole in the neo-breast, the native side can be corrected with an implant. In thigh-based flaps, the upper pole filling is occasionally inadequate, necessitating AFG for volume and contour refinement. TMG/PAP, transverse musculocutaneous gracilis flap/profunda artery perforator flap.

Procedure planning

Markings are carried out on the standing patient, putting meticulous emphasis on the symmetry to both sides. This is critical to maximizing the symmetry, especially in cases of irradiated tissue, as it tends to be rigid and shows other aspects than natural breast parenchyma. Contour abnormalities or volume discrepancies requiring treatment are carefully marked in order to treat correct areas intraoperatively. In the operating room, the patients are placed in a prone position, with the possibility of a seated position (almost 90°) on-table. The majority of procedures are conducted under general anesthesia in an outpatient setting.

Correction of volume discrepancies and shaping of the flap

A frequent reason for revisional surgery is an existing volume disproportion. In unilateral breast reconstructions volume asymmetry can be the result of a flap that is too large or too small to match the opposite breast; in bilateral breast reconstructions volume discrepancies may arise in comparison to preoperative breast size and shape. On the one hand, the problem can be a total excess or deficiency of volume, usually due to the initial correlation between the flap volume and the skin envelope in the primary reconstructive procedure. In cases with an abundance of skin and relatively sparse flap tissue, breast shape becomes ptotic. In contrast, when flap volume is high and skin volume almost insufficient, the breast mound appears compact and elevated following the reconstructive procedure. Normally, autologous breast reconstructions are created slightly larger than the opposite breast, with the anticipation that the volume will decrease over the first couple of months after surgery. If this is not the case, refining procedures follow.

On the other hand, volume loss or surplus can also appear to be localized in different breast quadrants, usually due to a certain initial insetting and shaping of the flap. Especially in bilateral cases the options of flap shaping are limited due to the given shape of the hemi-abdomen, which can result in a breast mound without desired projection, cleavage and lateral contour. Another reason for localized volume deficiencies may be the result of partial flap loss. In a few cases the symmetry and overall appearance of the breast mound might seem appealing; however, patients complain of a volume excess in the lateral area. This is the case when the thoracodorsal pedicle is used as a recipient vessel, and a surplus of lateral flap tissue results due to flap positioning.

The various problems concerning volume incongruities can be summed up in two categories:

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  Total volume excess/deficiency

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  Partial volume excess/deficiency.

The aim of final breast mound shaping is to refine the size and shape, using various techniques as a means to sculpt the reconstructed breast. The main surgical tools include volume supplementation (autologous fat grafting) and volume reduction (liposuction and direct tissue resection). When there is a severe lack of volume in unilateral cases, either on the reconstructed or natural side, augmentation with an implant is a possibility to correct size inequality. These mentioned techniques can either be combined or used independently to achieve a satisfying result.

Correction of contour and structural irregularities

After autologous breast reconstruction, using either abdominal, gluteal or thigh-based tissue, contour abnormalities may occur. In most cases this can either be readily addressed by suction-assisted lipectomy of the subcutaneous tissues, or approached with autologous fat grafting in the area needed. Indentations, which can occur after partial flap necrosis, and unpolished contours are standardly treated with injection of fat tissue. Especially in gluteal-based flaps, it is regularly difficult to achieve a smooth transition to the surrounding tissue of the flap. Classically, a step-off in the upper and medial quadrants at the interface between neo-breast and chest wall is seen ( Fig. 43.1 ). In these cases, autologous fat grafting can provide a remedy.

The occurrence of fat necrosis, a well-recognized sequela, can compromise a breast reconstruction by causing firm to hard areas of the reconstructed breast that are not as soft or mobile as natural breast tissue. These areas can either be treated with suction-assisted lipectomy or direct excision. The latter technique, however, may result in an undesirable contour deformity and should be conducted with caution. Afterwards, in a second revision, fat grafting may be needed to treat the developed indention.