Plastic reconstructive procedures in breast cancer are possible both as part of tumour resection or the primary operation (immediate reconstruction) and at a later stage as delayed reconstruction.
The plastic surgical procedures serve to provide defect coverage, volume replacementand restoration of the patient’s physical integrity. Breast reconstruction does not appear to be associated with an increase in the local recurrence rate. Reconstruction of the amputated female breast can only be offered to a patient after comprehensive information about all existing options. Whether this measure has a favourable or unfavourable influence on the course of the disease has not yet been conclusively answered.
Goals of modern breast reconstruction
Creating a natural-looking breast shape
Creating a symmetrical nipple–areola complex
Avoiding a major donor-site defect, with the least conspicuous scar possible
Choosing a reconstruction procedure that is as simple and safe as possible
Keeping the burden of surgery and postoperative morbidity as low as possible
The choice of technique must be made individually for each patient.
Depending on the indication, reconstruction is possible with allogeneic implants, autologous tissue or a combination of both procedures. After previous radiotherapy, breast reconstruction with the patient’s own tissue is preferable to the use of expanders or prostheses, because irradiated tissue can only be stretched and shaped to a limited extent. Expander reconstruction after radiotherapy is relatively contraindicated.
Determining the timing of surgery
The decision whether to perform immediate reconstruction or plastic surgery at a later stage depends on the patient’s individual situation and wishes.
Single-stage approach: the advantages of a single-stage approach lie in the lower psychological burden, as with immediate breast reconstruction the patient experiences a sense of loss after removal of the breast gland to a lesser extent. Furthermore, particularly after skin-sparing mastectomy, the memory effect of the skin allows reconstruction of a more natural breast shape than is possible with delayed reconstruction.
Two-stage approach: delayed reconstruction gives women time after diagnosis and primary treatment to consider the
options for plastic reconstruction calmly. If a tissue expander has already been implanted before planned radiotherapy, it should first be filled completely and the tissue reaction after radiotherapy awaited, in order then to decide whether definitive implant placement or flap reconstruction could produce the better result.
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Implants for breast reconstruction
This method is mostly used for immediate reconstructionafter breast-conserving tumour resection, when a sufficiently large skin and soft tissue envelope is available. In delayed reconstructionsafter modified radical mastectomy (MRM), there is usually only a thin, retracted soft tissue envelope, so that an implant appears visually conspicuous and is clearly palpable. There is also an increased risk of capsular contracture. If breast reconstruction is performed with an implant alone, it is placed submuscularly (subpectorally) for better coverage, and the lower pole of the implant can be covered with a biological replacement matrix (Alloderm, Strattice sheet).
Advantages and disadvantages of implant reconstruction
Advantages:
Short operating time
Low perioperative complication rate
Disadvantages:
Palpable implant with thin soft tissue coverage
Capsular contracture
Foreign body sensation
Risk of rupture
Limited shaping options
Secondary shrinkage and deformity with adjuvant radiotherapy
Autologous tissue for reconstruction
Reconstruction with autologous tissue appears indicated particularly when the skin envelope is tight and the subcutaneous tissue thin, since transferring tissue together with an overlying skin island can compensate a relative skin deficit in addition to restoring volume. This procedure is therefore particularly suitable for delayed reconstruction after modified radical mastectomy (MRM) or after radiotherapy.
Advantages and disadvantages of autologous tissue for breast reconstruction
Advantages:
Natural consistency of the breast
Natural ageing behaviour
No secondary procedures (no implant exchange)
No foreign body/no capsular contracture
High acceptance, strong identification with the transplanted tissue
Disadvantages:
Technically difficult procedure
Increased complication rate; loss of the transplanted tissue is possible
