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Implant-based breast reconstruction
Synopsis
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Implant-based reconstruction
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Alloplastic breast reconstruction is the most common approach used today for postmastectomy breast reconstruction.
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Traditional breast implant reconstruction is performed as a planned two-stage procedure with the use of a tissue expander followed by exchange to a breast implant.
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Changing demographics of the mastectomy patient, improved devices and support matrices, as well as refinements in mastectomy techniques have allowed for expanded indications of direct-to-implant breast reconstruction.
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Enhanced collaboration between oncologic surgeons and plastic surgeons is necessary in order to maximize outcomes in immediate breast reconstruction.
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Increasing awareness of the indications for skin and nipple preservation together with improved devices, internal scaffolds, and judicious use of fat transfer allow for results that may approximate the appearance and feel of a natural non-operated breast.
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Nipple-sparing mastectomy is increasingly performed for treatment or prevention of breast cancer.
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Key points of the history and physical exam determine if the patient is a candidate for nipple preservation.
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Reconstructive goals include rebuilding the breast with nipple centralization.
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Outcomes data show excellent results in cosmesis and complication rates.
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Latissimus flap reconstruction
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Latissimus dorsi flaps continue to play a significant role in primary and secondary reconstruction of total and partial mastectomy defects.
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Relative to other forms of autologous breast reconstruction, the latissimus flap is reliable, technically simpler, and associated with fewer and more modest short-term complications.
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The latissimus flap is an important salvage option following failed prosthetic or abdominal-based reconstruction.
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Surgical variations exist – including the extended and minimally invasive latissimus flap – that allow the amount of autologous tissue to be tailored to the clinical situation.
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Complications at the flap donor site are generally minimal and limited mostly to seroma formation.
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The technical ease, favorable complication profile, and short operative/recovery times will ensure continued use of the latissimus flap in breast reconstruction.
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The latissimus flap includes a large well-vascularized flat muscle that is well suited for dealing with poorly vascularized or radiated defects, contour deformities following breast conservation therapy, or for covering an implant.
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Placement of a tissue expander under the latissimus muscle allows postoperative adjustment of breast volume and ultimately better symmetry with the opposite breast.
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Complete mobilization to reach medial breast defects may require the partial release (90%) of the latissimus dorsi insertion. This helps avoid the displeasing bulge in the low axilla; however, care must be taken to protect the thoracodorsal vessels.
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The extended latissimus dorsi flap is a reliable method for totally autologous breast reconstruction and can be considered a primary choice for breast reconstruction, particularly in women who otherwise are at high risk for a transverse rectus abdominis (TRAM) flap or an implant procedure.
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Brief introduction
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With increasing recognition of the value of immediate reconstruction for the mastectomy patient, the option of expander–implant became more practical for incorporation into techniques for reconstruction.
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The first stage is insertion of the expander, either at the time of mastectomy or delayed until the patient is referred or presents for reconstruction. If not performed at the time of the mastectomy, it is preferable to delay reconstruction by a minimum of 3 months and until adjuvant treatments are completed.
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Capsular contracture has been widely investigated as the major trade-off of prosthetic reconstructions.
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The beneficial effects of the acellular dermal matrix (ADM) in the prevention of long-term complications such as capsular contracture or poor morphological results may be hindered by a higher percentage of short-term severe complications, including seroma and infection.
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Advantages of the expander–implant technique for breast reconstruction include the following:
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Minimal morbidity.
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Reduced operative time.
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Although there are usually two procedures involved, each is relatively short and may or may not require a hospital stay.
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No donor site morbidity.
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If the patient becomes dissatisfied with the result, all preexisting flaps are still available.
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Disadvantages of the expander–implant technique for breast reconstruction include the below.
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Complications inherent to implant use are:
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Implant deflation or malfunction.
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Capsular contracture.
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Fear of adverse interactions between the patient's immune system and the device.
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Contour irregularities visible on skin surface due to the underlying implant.
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The implant will not behave like normal vascularized tissue:
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It will remain cooler than adjacent body parts when ambient temperature is low.
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The reconstructed breast will not develop natural ptosis with advancing age.
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As the number of breast cancer cases continues to rise, progressively more of these women are receiving adjunctive radiation and may not be candidates for implant-alone reconstructions.
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While the main workhorses of autologous reconstructions are abdominal-based flaps, the latissimus dorsi myocutaneous flap is an essential reconstructive option and has gained renewed interest due to its reliability, ease of dissection, versatility, and minimal donor site morbidity ( Fig. 20.1 ) .
Preoperative considerations
For expander/implant reconstructions
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General criteria for implant–expander reconstruction include an adequate skin envelope to support the expander–implant.
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The patient must be well-informed about all options for breast reconstruction.
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The patient must be willing to accept the use of a permanent prosthesis.
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Relative contraindications to implant-based reconstructions include previous radiation, skin fibrosis or scleroderma, and smoking, as these all portend a higher risk of complications (e.g., infection, capsular contracture, expander/implant failure).
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Postoperative radiotherapy is controversial, and the timing of expander–implant exchange with the adjuvant radiotherapy is often site/surgeon specific.
For latissimus flap reconstructions
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Particular attention is given to the amount of skin and subcutaneous tissue obtainable in the dorsal region.
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A good indication is given by pinching the lateral dorsal pad to estimate the thickness of the adipose layer.
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It is vital to compare the mass available with that which will be needed to achieve a suitable breast size.
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It is also important preoperatively to assess the function of the latissimus dorsi muscle.
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Denervated and non-functional muscle after an axillary dissection increases the risk of damaged thoracodorsal vessels or inadequate circulation.
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In this instance, the latissimus dorsi must be elevated on an intact serratus collateral pedicle.
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Functioning muscle is most often a favorable sign for the integrity of the pedicle; however, it does not guarantee intact thoracodorsal vessels.
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Indications for latissimus flap reconstruction include:
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Breast reconstruction after a skin-sparing mastectomy when a breast prosthesis is part of the plan.
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Partial mastectomy or lumpectomy deformities.
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Patients who are not candidates for a transverse rectus abdominis (TRAM) flap.
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Women who have had a previous abdominoplasty or TRAM flap, women with insufficient abdominal skin or fat, and women who smoke, have diabetes, or are obese and may be considered to be too high risk to undergo a TRAM flap.
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Previous irradiation during breast-conservative therapy.
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Excessively thin or unreliable skin flaps over an implant.
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After a previous mastopexy or reduction, as the skin flaps in these patients may be unreliable.
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Women who have had breast augmentation previously may select a skin-sparing mastectomy with a latissimus flap over their breast prosthesis.
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Large ptotic breasts.
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Contraindications to latissimus flap reconstruction include:
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Previous posterolateral thoracotomy in which the latissimus muscle had been divided.
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An atrophic latissimus muscle after division of the thoracodorsal nerve during an axillary dissection.
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Immediate latissimus reconstruction before radiation therapy.
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Anatomical/technical pearls
Expander/implant selection
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The size of the device used is largely based on breast width, size, and shape of the contralateral breast. It must also take into account the patient's wishes on contralateral symmetrization procedures.
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The expander should be usually the same height as the contralateral breast.
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The projection of tissue expanders is normally variable and depends on the level of inflation and amount of projection desired.
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