BREAST RECONSTRUCTION TECHNIQUES
IMMEDIATE BREAST RECONSTRUCTION
IMMEDIATE BREAST RECONSTRUCTION USING THE EXPANDER/IMPLANT TECHNIQUE STAGE I
Markings: Prior to mastectomy, the patient's inframammary folds and mid-line are marked. These markings will be used during surgery to help with dissection and correct placement of the expander.
Skin Flap Viability: Reconstruction proceeds directly following the mastectomy. The skin flaps remaining after the mastectomy are evaluated for viability. All potentially ischemic tissue is removed to avoid possible wound healing complications. If concern remains regarding the viability of the skin flaps, one ampule of flourescein may be given intravenously and a Woods Lamp can be used to help assess perfusion.
Selection of the Expander: The base width of the existing breast is the most important measurement in selecting the size and style of an expander. A plastic template supplied by the manufacturer (McGhan) is used to confirm the match. Once the measurements are confirmed, an appropriately matched McGhan style 133 anatomic textured tissue expander with an integral injection port is chosen.
Creation of the Muscle Pocket/Expander Placement: A muscle pocket is created for the tissue expander. The pectoralis major is elevated superiorly and medially, beginning at the lateral edge. The serratus anterior and anterior fascia of the rectus are elevated downward. It is possible the pocket may not be intact, particularly the lower portion, nonetheless it is crucial to provide a muscular separation between the expander and the skin/mastectomy incision. Prior to placement, all air is removed and the expander is filled with saline to check for leaks. Once the expander is cleared for leaks, it is filled with 50 to 100 cc of saline. The selected expander is then inserted with the integral injection port placed superiorly in the pocket (see Figure 1). The muscle edges are approximated over the expander with interrupted 3-0 vicryl sutures.
Closure: A closed drainage system is recommended. A Jackson-Pratt 10 French fully perforated flat drain with bulb suction is used to prevent fluid accumulation. The drain is inserted into the pocket through a separate lateral stab incision and secured with 2-0 nylon sutures. The skin is approximated in layers using 3-0 vicryl sutures in the muscle and subcutaneous layers. A 4-0 prolene subcuticular running suture is used to approximate the skin edges.
Expansion: Tubing and attached 21 gauge needle are primed using saline to remove all air. The injection port is then palpated and a McGhan magnaport finder (magnet) is used to verify the location of the integral port. The needle is inserted into the integral injection port until the steel backing is struck and then aspirated to ensure proper positioning. A measured amount of saline is injected into the expander - 50 to 200 cc is the standard amount injected during an expansion session. The volume injected is restricted by the point at which the patient begins to feel tightness or discomfort.
Expansion Process Overview: Breast expansion begins two weeks after the mastectomy if the incisions are healing well. Concerns regarding healing may postpone expansion until the status of the wound is satisfactory. Expansion occurs weekly until the expander is 10 percent larger than the native breast, at which point the process is stopped and the second stage implant exchange is planned four months later.
IMMEDIATE BREAST RECONSTRUCTION USING THE EXPANDER/IMPLANT TECHNIQUE STAGE II
Pre Expander/Implant Exchange: Prior to the expander/implant exchange, the status of the expanded breast mound is compared in relation to the patient's native breast. Markings are once again made, identifying the mid-line and inframammary creases.
The previous incision is used to remove the expander. If necessary, adjustments are made in the capsule surrounding the expander to achieve symmetry with the contralateral breast. The inframammary crease may need to be lowered by incising the lower portion of the capsule, or elevated by using a 3-0 merselene suture to recreate a precise higher inframammary fold. Ideally, no alterations are necessary and the permanent implant can be placed immediately.
Implant Selection: The selection between the McGhan style 363 and the McGhan style 163 implant is made based upon the shape of the patient's native breast. The implants differ in the design of the upper pole (see Figure 2).
The McGhan style 163 is slightly taller than it is wide, with a contoured upper pole and projecting lower pole. While the McGhan style 363 implant has a projecting lower pole, but is shorter than it is wide. The style 363 implant creates a greater concavity of the upper pole of the reconstructed breast. Typically I use the style 163, but will on occasion select the style 363.
Implant Placement: Prior to its placement in the muscle pocket, the air should be removed from the implant and then filled to the appropriate volume with sterile saline and checked for leaks. The implants have very sensitive predetermined volume ranges. For example, underfilling can risk underinflation and rippling in the newly reconstructed breast. In addition, both overfilling and underfilling can result in implant rupture. Final judgment and correction of implant placement can be made by sitting the patient upright and making any necessary adjustments.
Closure: The wounds are closed in layers using 3-0 vicryl sutures on both the muscle and the subcutaneous layers. The skin is approximated with a subcuticular 4-0 prolene suture. To prevent fluid accumulation, a 10 French Jackson-Pratt flat-drain with bulb suction is used. The drain is brought out through a separate stab incision laterally and secured with a 2-0 nylon suture. Two-inch 3M microfoam tape is then placed in the inframammary crease to maintain its position. Sterile dressings and a surgical bra from Baxter are subsequently placed on the newly reconstructed breast.
Bilateral Breast Reconstruction: If the patient undergoes bilateral breast removal, care must be given to create symmetric inframammary folds.
IMMEDIATE BREAST RECONSTRUCTION WITH AUTOGENOUS TISSUE TECHNIQUE TRAM FLAP
The transverse rectus abdominus myocutaneous (TRAM) flap is the choice donor tissue for this technique. It can be used for bilateral reconstruction and post radiation treatment. However, this method is not used if the pedicle is transected or if scars from previous surgeries restrict use.
Mastectomy Incision: If possible, a circumareolar incision is utilized for the mastectomy. If the breast is large a wider circle is taken around the nipple areolar complex. If needed, either a lateral extension or a separate incision in the axilla can be used to facilitate the axillary dissection. These incisions optimize the reconstructive outcome without jeopardizing oncologic principles.
Donor Site Incisions: Prior to surgery, the inframammary fold is marked. The initial donor site incision is made one to two centimeters above the umbilicus and extends in a curvilinear fashion from anterior superior iliac spine (ASIS) to the contralateral ASIS.
The incision is carried down through the subcutaneous tissue and beveled upward to the anterior fascia of the abdominal wall. The beveling is performed to incorporate as many perforating vessels as possible. The dissection is continued upward on the anterior fascia of the abdominal wall - with the central portion of the abdomen as the primary area of focus for dissection. The superior dissection is completed by the creation of a tunnel between the mastectomy site and the abdominal dissection. This tunnel should be large enough to allow the passage of the surgeon's hand in anticipation of transferring the TRAM flap.
Mobilizing the TRAM Flap - Focus on Umbilicus: Next, the patient is flexed at the hips and the anterior abdominal wall is transposed over the lower abdominal skin flaps demonstrating the amount of tissue that can be safely incorporated into the flap (see Figure 4).
This area of overlap is marked in a curvilinear symmetric fashion from ASIS to the contralateral ASIS, connecting to the superior incision. The incision then follows the marking and is centrally beveled downward to the anterior abdominal wall fascia. The umbilicus is then mobilized. Two skin hooks are placed above and below, elevating the umbilicus. A no. 11 scalpel blade is used to make an incision along the perimeter of the umbilicus. The hooks are then transposed laterally where the incisions have been made and once again the umbilicus is elevated - the incision around the umbilicus is now completed. Scissor dissection is then performed around the umbilicus, maintaining a cuff of subcutaneous tissue to preserve the blood supply to the umbilicus.
Mobilizing the TRAM Flap - Focus on the Rectus: The rectus contralateral to the side of the mastectomy is utilized as the pedicle for the TRAM flap. Attention is focused on the lateral edge of the TRAM flap on the opposite side of the rectus abdominus pedicle. This portion of the flap is elevated off the anterior wall fascia across the anterior rectus sheath, just across the mid-line to the medial edge of the rectus abdominus pedicle. Attention is now given to the lateral edge of the TRAM flap on the pedicle side which is elevated off the anterior abdominal wall fascia to the lateral edge of the rectus abdominus pedicle. At this point careful dissection is performed until the first perforators are visualized - extending through the rectus abdominus muscle, the fascia and into the flap itself. Caution must be taken not to harm the perforators because such damage could lead to partial or even complete loss of the flap. Attention is now focused on the anterior rectus fascia overlying the rectus abdominus muscle. The fascia overlying the rectus abdominus muscle is transected along the lateral edge from the costal margin down to the pubis. In a similar fashion the medial edge of the fascia overlying the rectus abdominus muscle is also transected. Special care must be given to dissection in the area of tendonous inscriptions where the fascia is very adherent in order to preserve perfusion of the flap.
Mobilizing the TRAM Flap - Final Steps: Next, attention is focused on the lower lateral aspect of the rectus abdominus muscle. The rectus muscle is elevated off the peritoneum. Then the inferior epigastric artery and vein are identified, double clamped and transected. The proximal portion is tied with a 3-0 silk suture, while the distal portions that remain attached to the rectus abdominus muscle are occluded with hemoclips. The rectus abdominus muscle inferior to the skin flap is mobilized and transected using electrocautery. The rectus abdominus muscle with the flap is elevated off the posterior rectus sheath. The large vessels entering the rectus abdominus muscle are controlled with hemoclips and then divided. Mobilization of the rectus continues up to the costal margin at which point the superior epigastric artery and vein are visualized. Care must be taken not to damage the pedicle during the superior mobilization of the rectus abdominus muscle. Although quite large, the pedicle is fragile and damage to the supplying vessels could lead to varying degrees of ischemia of the tissue.
TRAM Flap Examination and Transfer: At this point, the TRAM flap is fully mobilized and the cutaneous portion of the flap is examined. The central periumbilical area should demonstrate capillary refill with increasing ischemia in lateral directions. The lateral ischemic portions are excised. The excision of tissue continues until the remaining flap has bleeding from all cut edges. The excised portions of the flap are discarded. The remaining flap is transposed under the superior abdominal skin through the previously created tunnel and into the mastectomy site. Care must be taken during the transfer to avoid any tension on the rectus muscle which could damage the pedicle. After transfer, the flaps are again examined for viability and bleeding from all cut edges. If necessary further tissue is removed until only viable bleeding tissue remains. The flap is then temporarily positioned in the mastectomy site and attention is focused back to the abdominal area.
Donor Site Closure: The wound bed is irrigated with warm saline to remove all fragments of adipose tissue. The fascial defect left by harvesting the rectus abdominus muscle is reconstructed with a strip of marlex mesh sutured to the surrounding anterior abdominal wall fascia using a no. 1 prolene horizontal mattress suture. Three closed-suction, fully-perforated no. 10 Jackson-Pratt drains are then placed over the abdominal wound bed and brought out through separate incisions in the mons pubis. Interrupted 2-0 nylon sutures are used to secure the drains into the skin. The 12 o'clock position of the umbilicus is marked with a surgical skin staple for orientation. The superior abdominal skin flap is then approximated to the inferior abdominal wall skin flap in layers. The subcutaneous tissues are approximated using 10 to 15 interrupted 0 vicryl sutures. The subdermal subcutaneous tissues are approximated using 10 to 15 buried 3-0 monocryl sutures. And the skin edges are approximated using a 4-0 monocryl running subcuticular suture.
Reformation of the Umbilicus: Prior to complete closure, the umbilical stalk is palpated under the superior abdominal wall skin flap. The mid-line location of the new umbilicus is identified. The location of the new umbilicus should roughly coincide with the ASIS. A vertical incision is made into the skin and carried through the subcutaneous tissues. The umbilicus is transposed and sutured using an interrupted buried 5-0 vicryl suture with a running simple 5-0 chromic suture around the circumference of the umbilicus. The staple previously placed for orientation is removed.
Mastectomy/Flap Site Closure: Attention is now focused on the TRAM flap in the mastectomy site. The flap is again examined for viability and bleeding from its cut edges before it is contoured to recreate the patient's breast mound. The patient's mastectomy flaps are also examine for viability and debrided as needed. After assessing perfusion, the mastectomy flaps are brought up to cover the TRAM flap as needed to recreate the shape of the contralateral breast. Once the mastectomy flaps are in position, they are temporarily held in place using surgical skin staples. A marker is used to mark the area of exposed skin of the TRAM flap required for reconstruction. The surgical staples are removed and the edges of the flap are sutured to the chest wall fascia using interrupted 2-0 vicryl sutures. Only a few sutures are utilized to secure the flap to the chest wall fascia. The TRAM flap is then deepithelialized outside of the previously marked area of required skin.
Two no. 10 fully-perforated Jackson-Pratt drains are brought in laterally through two separate stab incisions and placed inferior and lateral to the TRAM flap. The drains are secured at their skin entry sites with 2-0 nylon sutures. The patient's mastectomy skin flaps are then repositioned using a surgical skin stapler. The mastectomy flaps are sutured to the skin of the TRAM flap using a running, subcuticular 4-0 monocryl suture. The surgical staples are removed as closure progresses (see Figure 5).
Post-Closure: After all staples have been removed and the closure of the wound is complete, sterile gauze dressings are applied over the breast and abdominal incisions. The patient is transferred from the operating table to her hospital bed in a flexed position to relieve tension on the abdominal wound closure.
Post-Op: Post-operatively the flaps are monitored for perfusion. The flap warmth, softness and capillary refill are checked every 30 minutes until the day following the procedure. The patient must be well hydrated with intravenous fluids to maintain excellent tissue perfusion. Patient fluid status is evaluated by monitoring vital signs and urine output - which should be maintained at 0.5 cc per kilogram per hour.
Bilateral Reconstruction: As opposed to single breast reconstruction where the breast is recreated using the TRAM flap contralateral to the mastectomy site, bilateral reconstruction requires the use of the ipsilateral side TRAM flap. The tunnels from the abdominal region are created leading straight up to the mastectomy site, with attention given to maintaining tissue separation between the two tunnels to avoid synmastia. A larger piece of marlex mesh is used to reconstruct the anterior abdominal wall fascia since both rectus muscles are used.
DELAYED BREAST RECONSTRUCTION
DELAYED BREAST RECONSTRUCTION USING THE EXPANDER/IMPLANT TECHNIQUE
In delayed reconstruction the patient has a flat chest with an oblique scar on the mastectomy site. Prior to surgery it is critical to mark the inframammary crease on the mastectomy side in mirror image to the native breast.
Entry into the Delayed Reconstruction Site: The lateral aspect of the mastectomy scar is entered and the lateral aspect of the pectoralis muscle is identified. The pectoralis is laterally elevated and a sub-pectoral pocket is created. The origin and medial attachment of the pectoralis major muscle are divided downward from the second to the fourth ribs. Preferably, the lower portion of the pocket should be in the subcutaneous position, free of all restraining scar and fascial elements. Attention should be given to the release of the inframammary fold, securing its exact and desired location as marked prior to surgery.
Placement of the Expander: Next, the style 133 McGhan expander is placed into the pocket with the integral injection port located at the top. The same steps are now followed as with immediate reconstruction.
Breast Taping: Once the wound is closed, the breast must be securely taped to reaffirm the inframammary fold and crease. Because the mastectomy site healed as a flat wound, the natural inframammary fold and crease have been destroyed. The tape must be placed carefully along the desired inframammary fold and crease, followed by a sterile dressing.
DELAYED BREAST RECONSTRUCTION USING THE TRAM FLAP TECHNIQUE
As with all reconstructive procedures, delayed breast reconstruction using the TRAM Flap technique requires careful, preoperative marking of the inframammary fold to match the native breast.
Entry into the Delayed Reconstruction Site: The mastectomy incision is excised and the skin along with subcutaneous flaps is elevated down to the inframammary fold. The dissection is then carried superiorly to the region of the clavicle, medially to the sternum and laterally to the edge of the latissimus dorsi muscle. The reconstruction then proceeds, elevating and mobilizing the TRAM flap as described for immediate reconstruction.
MANAGEMENT OF COMPLICATIONS
Hematoma: In case of hematoma formation, operative exploration of the surgical site and evacuation of the hematoma are required. To maximize sterility and minimize potential injury to the expander or implant, evacuation of the fluid is performed in an operating room.
Infection: If infection occurs, the entire expander or implant must be removed and the implant pocket drained. A Jackson-Pratt no. 10 fully perforated drain is used. The drain is placed into the implant pocket once the expander/implant is removed and remains in position until the output is less than 30 cc during a 24-hour period. Perioperative, broad-spectrum antibiotics are given preoperatively to the patient and continued until all inflammation has subsided. Prior to surgery, cefazolin is given intravenously, followed by oral doses of cephalexin for ten days. The selection of antibiotics may change based upon cultures obtained during implant removal. Following a six month interval, reconstruction using the expander/implant technique can again be attempted.
Capsular Contraction: The fibrous capsule surrounding the implant can contract to such a degree that may result in deformity of the shape of the breast mound as well as pain. In symptomatic patients, the only option is to perform a capsulectomy (removal of the implant capsule) and replace the implant.
TRAM FLAP COMPLICATIONS
Hematoma: Hematoma formation requires immediate operative evacuation and exploration of the surgical sites to control any ongoing bleeding. The procedure is performed in an operating room to maximize sterility and minimize risk of infection.
Wound Healing Difficulties: Wound healing difficulties are most commonly the result of necrosis of the mastectomy flap edges and/or the abdominal wound closure edges. If tissues appear necrotic the patient is immediately brought to the operating room, the necrotic portions excised, and the wound re-closed. It is vital that the tissue is removed promptly in order to avoid bacterial colonization or infection.
Loss of Umbilicus: Poor perfusion can lead to loss of the umbilicus. If the umbilicus becomes necrotic, the tissue is excised and the abdominal wall is closed. Again, excision of the necrotic tissue is performed immediately to avoid bacterial colonization or infection. Reconstruction of the umbilicus can be attempted after six months.
Incisional Hernia: Abdominal wall laxity may occur in the area from which the rectus abdominus has been harvested. Treatment requires repair of the abdominal wall laxity using marlex mesh.
Partial/Complete Flap Loss: Partial flap loss is rare. Should it occur, excision of necrotic portions is required, followed by wound closure.
Complete flap loss is very rare and typically occurs during elevation. If the flap is not viable, it is discarded. The abdominal incision is closed using the method described in the TRAM donor site closure section, whereas the mastectomy wound is closed without reconstruction. Reconstructive alternatives are then discussed with the patient after recovery from surgery.
POST-CONSTRUCTION PROCEDURES & CONCERNS
Tram Flap Revisions/Contouring: Approximately four to six months after initial reconstruction, the TRAM flap may require contouring revisions. These revisions may be performed by direct excision of tissue or by using liposuction to contour the breast mound. Nipple/areolar reconstruction may be performed at the same time.
Nipple/Areolar Reconstruction: The nipple/areolar reconstruction can be performed under local anesthetic since sensation from the breast mound is either entirely absent or diminished. Multiple techniques are available for reconstruction of the nipple and areola. The patient's native nipple/areolar complex serves as a template. The Skate Flap Method is used for nipple/areolar reconstruction.
Areolar Reconstruction: To reconstruct the areola, a full thickness skin graft is harvested from the non-hair bearing inguinal crease. The area surrounding the reconstructed nipple site is deepithelialized to match the areola on the native breast. The skin graft is placed over the raw surface to reconstruct the areola. A running 5-0 plain suture is used to secure the skin to the graft. Once the skin graft is secured, the entire reconstructed nipple/areolar complex is covered with a xeroform bolster. The bolster is held in position using multiple 2-0 nylon sutures, placed cirumferencially around the nipple/areolar complex - typically 6 sutures are used. The bolster is removed five days after surgery. The skin graft will darken with time.
Nipple/Areola Pigmentation: Approximately four to six months after nipple/areolar reconstruction, the patient may have the area tattooed to match the color of her native breast. (The Permark tattooing system is used.) The initial tattooing should be performed with a color several shades darker than the patient's native nipple areolar complex to anticipate fading as the tattooed area heals.
ALTERNATIVE RECONSTRUCTION METHODS
LESS FREQUENTLY USED ALTERNATIVE METHODS OF RECONSTRUCTION
Depending on individual circumstances, alternative methods of reconstruction may be used. Below are two alternative methods:
Latissimus Dorsi Myocutaneous Transposition Flap and Implant: This method may be used for both immediate and delayed reconstruction. This procedure is similar to the TRAM Flap technique in that it utilizes autogenous tissue for breast reconstruction. However, in addition to the autogenous tissue transfer, an implant may be required to achieve adequate size. This method leaves the patient with a scar in the back area. Typically this technique is used when the TRAM Flap is not available.
Free Tissue Transfer: This method may also be used for immediate and delayed reconstruction. The tissue flap is removed with its supplying artery and vein from the donor area. The TRAM flap is most commonly selected as the donor site and can be transferred based on the inferior epigastric artery and veins. The epigastric vessels are connected to the thoracodorsal artery and vein in the axilla. If the thoracodorsal artery and vein are not available the internal mammary artery and vein can be used. This technique involves increased operating time and risk of complete flap loss.
The leaps in plastic surgery advances have increased the number of techniques available for breast reconstruction patients, making the selection of a specific technique a difficult one. It is therefore the role of the plastic surgeon not only to perform the procedure, but to guide the patient in the selection process.
The reconstruction of the breast plays a significant role in the patient's ability to deal with breast cancer. Although not perfect, reconstruction attempts to restore wholeness to the body. A reconstructed and once again complete body can help a mastectomy patient achieve a more positive body image - helping to overcome breast cancer as a disease.
The plastic surgeon works cooperatively with the patient's overall oncological treatment schedule. Care is given so that secondary revisional procedures avoid interference with adjuvant therapy and provide a lasting result. Reconstructive results are judged in comparison to the opposite breast - regardless if the breast is native or reconstructed, symmetry is the goal.
With the number of treatment options available, all women undergoing mastectomy or breast surgery are candidates for some form of reconstruction - no one is excluded.
HELPFUL BREAST RECONSTRUCTION RESOURCES
TransMed Online Management of Breast Diseases - Excellent resource for breast disease and medical management. The above article was only one of many helpful, informative resources.
Sutter Health Cancer Information: Breast Reconstruction Techniques