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22114—PRINCIPLES OF BREAST RECONSTRUCTION
No axillary incision
A
Figure 14–15. A, B, When the biopsy scar is further away from the areola, alternate incisions can be used to
excise them together while still preserving a maximum amount of natural skin. (From Bland K, Copeland E.
The breast, 3e. Philadelphia: Elsevier, 2004.)
reconstruction are not perfect, the presence of
B
Timing of Breast Reconstruction
Axillary incision
necessary
Reexcision
with1-cm margin
a reconstructed nipple does contribute significantly to the illusion of having recreated a
normal breast. Patients are therefore encouraged to undergo nipple reconstruction and
complete the process of breast reconstruction
whenever possible.
Historically, all reconstruction was delayed so
that thereconstructed breast would not interfere
with the detection of recurrent disease. Reconstruction was only performed in patients with
early-stage disease and often delayed for 2 years
because most recurrences occur within 2 years
Treatment of the Contralateral Breast
An important aspect of reconstruction is symmetry. Given the limitations of expander/
implants and autogenous flaps, it may not be
feasible to reconstruct the absent breast to
the same size as the remaining breast. Or in
a small-breasted woman, the reconstructed
breast may be larger than the contralateral
size. Therefore, women may require breast
reduction, breast augmentation, or a breast lift
(mastopexy) to create symmetry. This can be
done at the same time as the reconstruction
or at a later date. However, it is important to
point out that breast reconstruction does not
always produce a breast that is symmetrical
to the contralateral side.
of mastectomy. These practices have been abandoned, and today patients may choose to have
their reconstruction performed simultaneously
with mastectomy (“immediate”), or they may
wish to undergo mastectomy and then return
for reconstruction aftercompletion of their adjuvant therapies (“delayed”). Even in the more
recent past, delayed reconstruction was preferred secondary to concerns that complications
of reconstruction could delay adjuvant therapy,
putting patients at increased risk of recurrence.
Subsequent studies have failed to demonstrate
any increased risk with immediate reconstruction, so this method is an appropriate choice.
However, there are several relative advantages
and disadvantages to immediate versus delayed
reconstruction (Table 1 4–2).
222 SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY
Axillary incision
Tumor
Incision
with 1-cm margin
A
B
No axillary incision
Tumor
Incision
with 1-cm margin
Axillary incision
Tumor
Reexcision
with 1-cm margin
C
Figure 14–16. A-D, Additional options for excising both the nipple-areolar complex and biopsy scar for skinsparing mastectomy. (From Bland K, Copeland E. The breast, 3e. Philadelphia: Elsevier, 2004.)
D
No axillary incision
Tu mo r
Reexcision
with 1-cm margin
Figure 14–17. The biopsy
scar may also be excised separately from the nipple-areolar
complex. It is important that
the island of skin between the
two incisions be well perfused.
(From Bland K, Copeland E.
The breast, 3e. Philadelphia:
Elsevier, 2004.)
Unclosed
excision site
for previous
incision scar
Pectoralis
muscle in base
22314—PRINCIPLES OF BREAST RECONSTRUCTION
Via axillary incision
Breast
Excised skin
(1-cm margin)
of previous
biopsy scar
Immediate reconstruction has the obvious
benefit of avoiding the psychological impact
of waking from surgery without a breast. It
also reduces the number of times the patient
needs to undergo general anesthesia. By using
as much of the native skin of the breast as
Axillary incision
Breast
Figure 14–18. Skin flap elevation during the skinsparing mastectomy moves in a centripetal fashion to
provide optimum exposure. (From Bland K, Copeland
E. The breast, 3e. Philadelphia: Elsevier, 2004.)
possible, this improves the cosmetic outcome.
Immediate reconstruction can be an excellent
option for patients with ductal carcinoma in
situ (DCIS) or with early-stage disease. Autogenous tissue reconstructions performed at the
time of the mastectomy tend to have better
aesthetic results than delayed procedures
because this allows for a skin-sparing mastectomy to be performed. Recovery is faster and
overall cost is reduced.
Delayed reconstruction has its advantages as
well. For the patient who is unsure about
reconstruction, it allows time to make the
decision. Many patients are not as disappointed with the absent breast as they thought
they might be and ultimately decide to forego
reconstruction. The recovery period from the
simple mastectomy is quicker. Patients do not
typically have much choice about when they
need cancer surgery, but they can delay the
reconstruction until they have more time for
recovery. In addition, it is usually easier and
faster to schedule a simple mastectomy than
for the breast surgeon and the plastic surgeon
to find time for a combined procedure.
Patients can also proceed quicker to adjuvant
therapy, if necessary, after a simple mastectomy. It is important to point out, however,
that most studies have shown no significant
delay in adjuvant therapy with immediate
reconstruction. With delayed reconstruction,
the nodal status is known, so there is no
chance of having to return to the operating
room for an ALND after reconstruction or
the need to irradiate the reconstructed breast.
224 SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY
Figure 14–19. Local flap nipple reconstruction. A, Markings. B, Flap elevation, C, Flap rotation, D, Final
appearance. (From Roses D. Breast cancer. Philadelphia: Elsevier, 2005).
TABLE 14–2Relative Advantages
of Immediate versus Delayed
Reconstruction
Immediate
Reconstruction
Avoidance of second
operation
Lower cost No delay to adjuvant
Possible better
cosmetic outcome
Better scarring,
increased skin
availability (skin
sparing)
No period of time
without breast
Delayed
Reconstruction
Less complexity, shorter
operations
therapies
Less need for integration
of radiation and
reconstruction
Allows additional time to
consider reconstruction
and what time
Increased satisfaction of
reconstruction
compared with absent
breast, as compared to
previous breast (some
women expect an exact
duplicate)
The avoidance of postmastectomy radiation to
the reconstructed breast is one of the strongest
arguments for delayed reconstruction.
Breast Irradiation and Reconstruction
The most challenging aspect of incorporating
reconstruction in with breast cancer therapy
is the interaction of radiation therapy and
reconstruction. Over the past several years,
the indications and use of postmastectomy
radiation have risen (see Chapter 15). Indications for postmastectomy radiation include
the size of the primary tumor (>5 cm), close
margins after mastectomy, or four or more positive lymph nodes. The benefit of postmastectomy radiation for patients with one to three
positive lymph nodes is still debated, but its
use is increasing. It becomes obvious,
therefore, that a percentage of patients who
are scheduled to undergo mastectomy may fall
into one of these categories once the final
pathology is known. If a patient opts to have
immediate reconstruction, the situation may
arise that radiation needs to be delivered to
the reconstructed breast.
Delivery of radiation to the reconstructed
breast may present some challenges to the
radiation oncologist. Some reconstruction
techniques distort the chest wall anatomy, so
radiotherapy portals may need to be modified.
A steeply sloping contour of the new breast
may make it difficult to match fields. The foreign material may affect the radiation dose distribution within the breast. All of these factors
must be taken into account during the radiation planning. With the use of computed
tomography (CT) based planning and immobilizing devices, radiation can still be safely and
effectively delivered to the reconstructed
breast and chest wall, with no compromise of
local recurrence rates or increased damage to
the lung or heart. So in the hands of an experienced radiation oncologist, the reconstruction should not markedly affect the radiation
dose distribution. However, the radiation may
affect the reconstruction.
Effects of Irradiating a Tissue Expander/Implants
Postoperative radiation when an implant has
been placed is generally contraindicated. However, there are situations where only after an
expander has been placed does the possibility
of postmastectomy radiation arise (such as a
positive margin or positive lymph nodes). If
it is known that radiation will be used, reconstruction can be delayed, although this is not
without increased complications. If, however,
the expander has already been placed (or the
patient is strongly against delayed reconstruction but not a candidate for a flap), the options
22514—PRINCIPLES OF BREAST RECONSTRUCTION
include performing the radiation before
expansion, after tissue expansion but before
placement of the permanent implant, or after
placement of the implant. Radiation before
expansion means expansion of the recently
irradiated field. Radiating after the expansion
process is complete means having to replace
the expander with the implant in the face of
acute radiation changes. The radiation should
be delayed until the acute changes have settled but ideally before chronic radiation
changes set in, or the radiation can be delayed
until after the placement of the final implant.
However, this means a delay in radiation,
which may decrease its effectiveness. This will
in part depend on whether the patient will be
receiving systemic therapy. If chemotherapy
is to be used, a good option is to expand during the chem otherapy and then do the
exchange 3 to 4 weeks after chemotherapy
finishes. The radiation is initiated, 3 to 4
weeks later.
Radiating an expander or permanent implant
will increase the rate of capsular contracture.
However, despite the fact that the radiation
of an expander or an implant is often described
as contraindicated, that is not the case. Despite
an increased rate of contracture, successful
reconstruction is still accomplished in most
patients. Although aesthetic outcomes as graded by the surgeon or independent observers
are less than when radiation is employed, these
rates can still be acceptable. More importantly,
the difference in patient opinions between
implants after mastectomy alone and implants
followed by radiation does not appear to be
as significant as physician or third-party opinions, at least in the short term. Satisfaction
rates do tend to separate more by 5 years,
thought to be the result of progressive asymmetry between the natural and reconstructed
breast, which tends to be more pronounced
if the implant has been irradiated. It is also
important to keep in mind that delayed expansion and implants after radiation also have a
higher rate of complication rates.
Effects of Irradiating the Autologous Flap
If postmastectomy radiation is indicated, and
the patient does not want a delayed reconstruction, the ideal reconstruction is an autologous
flap. However, postoperative radiation after
a flap reconstruction may be associated with
increased wound complications and an altered
cosmetic outcome. A well-vascularized TRAM
flap should tolerate the 5000 to 6000 Gy
typically delivered to the chest wall after a
mastectomy. However, an individual patient’s
response to radiation may be quite variable,
and the resulting edema and fibrosis can
significantly alter the shape and softness of
the reconstructed breast. The resultant volume,
contour, and symmetry loss is unpredictable and may require additional surgeries
to correct the radiation-induced changes,
which may not always be as successful as
hoped.
For this reason, many plastic surgeons
would recommend that if it is known that
the patient will need postmastectomy radiation, or it is suspected that this might be the
case, consideration should be made to delaying the reconstruction until 3 to 6 months
after the completion of radiation therapy.
It i s still debated by plastic surgeons whether
delayed autologous reconstruction after radiation is trul y superior to immediate autologous radiation followed by radiation. Many
plastic surgeons report excellent outcomes
with autologous flaps after post-mastectomy
radiation.
Effects of Placing a Prosthesis after Irradiation
It is generally accepted that if postmastectomy
radiation is necessary and expander/implant is
the reconstruction of choice, then it is best to
do the radiation first, followed by delayed
placement of the expander. However, reconstruction of the irradiated chest wall after mastectomy still has complications. The effects of
radiation limit the success of tissue expansion.
The expansion process is associated with
increased pain, less leeway in overexpansion,
rib cage contour deformities, a greater infection rate, and expander extrusion. Compared
to expander/implants in the nonirradiated
breast, the resultant breast may be harder,
asymmetric and lack projection. Some series
have reported complication rates (including
unfavorable aesthetic results) as high as 60%
and an increased use of capsular contracture
releases, additional tissue coverage and other
additional procedures.
If, after the patient has recovered from radiation, the flaps show little evidence of radiation
damage, or the amount of skin expansion
needed is not excessive, expansion after radiation can be done safely with an increased but
not unreasonable complication rate. If, however, the skin shows clear evidence of radiation
226 SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY
induced changes, or a significant volume is
needed for symmetry, it may be preferable to
combine a latissimus dorsi flap with the tissue
expander or breast implant. This allows the
use of nonirradiated, well-vascularized tissue
for reconstruction. The latissimus dorsi readily
covers the device and expands nicely. In addition, the skin island that comes with the flap
can replace heavily irradiated skin.
Effects of Performing an Autologous Flap after Irradiation
The ideal choice for reconstruction when postmastectomy radiation is needed is a delayed
autologous reconstruction using any of the
aforementioned methods. It is worth noting
that pedicled TRAM flaps have a higher rate
of fat and skin necrosis when their pedicle
has been exposed to radiation preoperatively.
Free TRAM flaps have a lower complication
rate than pedicled TRAM flaps in irradiated
beds. There is a slightly higher rate of healing
complications secondary to the irradiated tissue’s ability to heal. To overcome this, it is prudent to use a larger amount of skin from the
flap and excise a correspondingly wider area
of the irradiated, fibrotic chest wall skin.
Sentinel Node Biopsy and Reconstruction
Two recent changes in the management of
breast cancer have altered the clinical scenario;
the introduction of SLN biopsy (see Chapter
13) and the suggestion that post-mastectomy
radiation may be beneficial in patients who
are node positive, including patients with
one to three positive nodes (see Chapter 15).
This has introduced the not uncommon scenario of a patient who is clinically node negative, requires (or desires) a mastectomy and is
interested in immediate reconstruction. Those
patients who turn out to be node positive, will
not only need to return to the operating room
for an ALND (which can be performed after
immediate reconstruction) but will be candidates for postmastectomy radiation. This
might mean radiating an expander or implant
or radiating an autologous flap, both of which
appear to have higher complication rates than
performing the reconstruction after the radiation is complete.
The optimal management will depend on
the stage of the primary cancer (and thus
the likelihood of finding regional metastases), the chosen method of reconstruction,
the need for systemic therapy (thus delaying
the radiation), the opinion of the plastic surgeon on radiating the reconstructed breast,
and the opinion of the radiation oncologist
on th e relative benefits of chest wall radiation
depending on the number of involved nodes.
In some cases it may be reasonable to proceed
with mastectomy, SLN biopsy and reconstruction and wait until the final pathology report
to decide on the relative pros and cons of
radiating the reconstructed breast. However,
in some cases it may be preferable to take
the patient to the operating room for a SLN
biopsy alone. Frozen section should be
planned on, with ALND performed if the
SLN positive. Often this procedure can be
combined with a ligation of the inferior epigastric vessels if a pedicled TRAM flap is
planned. If the nodes are negative, the patient
returns to the operating room for a mastectomy and reconstruction with minimal risk
of needing postmastectomy with external
beam radiation thera py. If the nodes are positive, a discussion can be held with the patient
and reconstruction potentially delayed.
Oncoplastic Approaches to Lumpectomy
The ultimate goal of breast conservation therapy is to both remove the cancer with an
adequate surgical margin and maintain the
breast’s shape and appearance. This can be
difficult depending on the tumor size and
location. When a tumor is too large to accomplish this goal, the surgeon typically has
two options. The first is to perform a mastectomy with reconstruction, and the se cond is
to give neoadjuvant chemotherapy in hopes
of downstaging the primary tumor to allow a
more cosmetic lumpectomy. For situations
in which neither option is desirable, a third
possibility is using oncoplastic techniques
for the lumpectomy. The term oncoplastic sur-
gery refers to a host of volume displacement
operations in which the defect created by a
large lumpectomy is filled in using a breastflap mastopexy closure; advancing breast
tissue along the chest wall to help fill in the
defect, using a full-thickness segment of
breast fibroglandular tissue.
With a typical lumpectomy, the resulting
defect is spherical or oblong in shape and left
to fill in with seroma fluid and then reabsorb
at radiation. If this defect is large, leaving
22714—PRINCIPLES OF BREAST RECONSTRUCTION
redundant skin over the defect, infolding can
occur so that the skin adheres to the chest wall
and the nipple deviates toward the lumpectomy site. Oncoplastic approaches to lumpectomy use full thickness lumpectomies, with
an overlying skin island removed with the
lumpectomy and the fibroglandular tissue
resected down to the chest wall. The goal is
that there is no direct contact between the
skin and the chest wall to prevent this indenting. After the lumpectomy, the breast gland is
lifted off of the pectoralis muscle with preservation of the fascia over the muscle. This is
advanced over the chest wall and the defect
is then closed. If advancement of the tissue
seems as though it will displace the nipple-areolar complex, this can be avoided by widely
undermining the nipple-areolar complex at
the level of the pectoralis fascia, which allows
the tissues to shift to an anatomically natural
position.
When doing so, the vascular perforators
between the pectoralis and breast must be kept
in mind. However, the extensive collateral circulation of the breast allows much flexibility
for oncoplastic techniques. Once the fibroglandular tissue is mobilized, the breast defect
is closed at full thickness. The deep margin of
the advanced breast tissue is sutured at the
deepest and most superficial edges, and the
skin is reapproximated. This decreases the size
of the seroma cavity and prevents the skin
from adhering to the chest wall, resulting in
a better cosmetic outcome.
The removal of a skin island will often cause
a distortion of the breast. In some cases,
excision of a large amount of skin will cause
upward displacement of the nipple-areolar
complex, which can be quite awkward looking. In this situation, it is better to use a linear
incision in the skin and not remove any skin
island. When a skin island is to be resected
with the specimen, the ideal defect has superior and inferior margins that are equal in
length. A useful design is a rounded parallelogram (Fig 14–20). The two skin incisions are
tapered at the corners so that the two incision
lines can approach each other easily at the corners, diminishing the V angle at the corner
and minimizing any dog ear. Full thickness
excision is performed with advancement of
the fibroglandular tissue.
A useful approach for cancers underneath
the nipple-areolar complex is the batwing
mastopexy (Fig 14–21). Two closely similar
half-circle incisions are made with angled
wings to each side of the areola. Full thickness
excision is performed with advancement of
the fibroglandular tissue. This will minimize
the defect and maintain the natural shape
of the breast, however, it will cause lifting of
the nipple, resulting in asymmetry. A contralateral lift will be necessary to alleviate the
asymmetry.
For large tumors in the lateral or upper
portions of the breast, the donut mastopexy
lumpectomy can be used. A donut of skin is
excised around the nipple-areolar complex
AB CD
Standard
lumpectomy
Parallelogram
mastopexy
lumpectomy
Figure 14–20. The rounded parallelogram is useful when skin needs to be excised.
228 SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY
Figure 14–21. Incision for the batwing mastopexy.
(Fig 14–22). This tissue ring is removed to
allow adequate access to the breast tissue.
A generous lumpectomy is performed down
to the chest wall and the remaining fibroglandular tissue is advanced and sutured at
both the deep and superficial margins. The
skin is reapproximated with a purse-string closure. Cancer in the lower part of the breast is
difficult because retraction of the lumpectomy
cavity will cause downturning of the nipple.
For large lesions in the lower hemisphere of
the breast, the approach used for breast reduction can also be used to perform a lumpectomy (Fig 14–23). The donut mastopexy and
reduction mastopexy are more challenging
oncoplastic techniques and surgeons without
specific training should be cautious.
There are several issues that need to be kept
in mind when the decision is made to perform
an oncoplastic resection. Positive margins are
often more difficult to deal with after an oncoplastic lumpectomy than with a standard
lumpectomy. Knowing the exact extent of
the cancer before and during the operation is
helpful, so preoperative magnetic resonance
Figure 14–22. Incision for the donut mastopexy.
imaging (MRI) and intraoperative ultrasound
may facilitate achieving negative margins on
the first excision. Taking additional margins
at the time of the lumpectomy will help minimize the likelihood of positive margins, especially considering that the close or positive
margin is often the result of ink running down
cracks in the fibroglandular tissue (especially
after wire localized specimens are imaged). As
with standard lumpectomy, specimens should
be inked with the six-color system so that the
surgeon knows which margin is positive. Some
surgeons ink their own specimens for optimum confidence. Using multiple colors allows
the surgeon to reenter the biopsy cavity and
excise the one or two margins of concern.
When a donut mastopexy or reduction mastopexy is used, reexcision may not be possible,
and a mastectomy is indicated for positive
margins. One advantage of the donut mastopexy is that the periareolar incision still allows
for a skin-sparing mastectomy.
Another concern with oncoplastic lumpectomy is the planning of the adjuvant radiation
therapy. The incisions used may confuse the
Figure 14–23. Incision for the reduction
mastopexy.
radiation oncologist as to the location of the
lumpectomy cavity. The placement of multiple
clips around the cavity will help, however, these
have to be placed carefully to truly represent the
extent of the cancer because the advancement
of fibroglandular tissue will distort the true
cavity. Oncoplastic techniques may also not be
compatible with partial breast irradiation
(PBI), in which knowledge of the cavity is essential to success. However, oncoplastic surgery is
typically reserved for big tumors and PBI is
typically not recommended for larger tumors.
Finally, oncoplastic techniques will often
maintain the natural shape of the breast and
avoid large indentations, but will often decrease
the volume of the breast. Many of these patients
will require contralateral breast reduction. This
can be doneat the same timeas the lumpectomy,
which helps avoid a second surgery or can be
done at a later date. Delaying the breast reduction until it is known that mastectomy will not
be necessary and the radiation is completed is
beneficial so that the contralateral breast can be
perfectly matched to the final result.
22914—PRINCIPLES OF BREAST RECONSTRUCTION
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