Breast Reconstruction

Breast reconstruction can be attempted with either:

  • Prosthetic implants
  • Autologous tissue flaps

Reconstruction can either occur at the time of mastectomy or as a delayed procedure (once chemotherapy and radiotherapy is complete if required); radiotherapy is a contraindication to immediate reconstruction with tissue expander (if radiotherapy is to be delivered during the expansion phase); autologous reconstructions should be delayed until radiotherapy has been completed to prevent radiation of the flap.

Timing of reconstruction

Immediate reconstruction has significant psychological benefits of delayed procedures. The disadvantage of immediate reconstruction is that the full pathological information (lymph node status, tumour size) may not be known at the time of surgery.

Breast Prostheses

These are usually silicon lined prostheses that contain further silicone or saline. They have had bad publicity on a number of occasions with minimal evidence. Breast prostheses can be used as:

  • Single step procedure: Less common due to a lack of skin for coverage. This procedure is best for women with smaller breasts (B cup or less) as they will likely have sufficient tissue left from the mastectomy for coverage. This is also possible when coupled with a skin sparing mastectomy.
  • Two step procedure: In this procedure, a tissue expander is inserted underneath the pectoralis muscle. The expander is gradually inflated every 1-2 weeks for a couple of months until the overlying skin has expanded sufficiently for insertion of the implant.

Breast prostheses are contraindicated in patients who require radiotherapy as they have a higher rate of complications, particularly capsular contractures (scarring) which can be induced by radiotherapy. Patients who are expected to require radiotherapy should be treated with delayed reconstruction with an autologous flap.

Autologous Flaps

There are several methods which transfer tissue from an adjacent part of the body into the anterior chest wall from which to fashion a new breast. These techniques are far more complex than the more straightforward prosthesis.

  • TRAM flap (pedicled or free): Transverse Rectus Abdominus Myocutaneous flaps are a popular method of reconstruction. Tissue from the anterior abdominal wall, including one or both rectus muscles, are freed up and migrated to the anterior chest wall, either as a free flap with reanastamosis to local vessels or by rotating the tissue 180o and passing it beneath the abdominal skin into the chest wall.
  • Lat Dorsi flap: Similar technique that uses latissimus dorsi instead of rectus abdominus. This technique provides less tissue but may be a suitable alternative.
  • Other flaps: Numerous other techniques are described, although most others are 'free flaps' which require harvesting of tissue elsewhere in the body and re-anastamosis to the chest wall vessels.

The main disadvantage of autologous flaps are higher complication rates and increased complexity when compared to breast prostheses.

Reconstruction and Radiotherapy

This is a controversial topic. It is known that radiotherapy significantly elevates the risk of capsular contracture with breast prosthesis (often with a risk of 10-20% in radiated patients versus 0-5% in those without). It can also impair the health of a tissue flap. Immediate reconstruction has been shown retrospectively to reduce dose homogeneity in breast cancer treatment.
Contrary to these arguments, breast prostheses are a much simpler operation with reduced complications in general when compared to autologous flaps.
A proposed alternative is the delayed immediate reconstruction. In this setting, a skin sparing mastectomy is performed and a tissue expander inserted. Prior to radiotherapy, the expander is deflated to allow for better dose distribution. It is then reinflated following radiotherapy and a delayed implant is inserted.

Opinion: I would recommend patients who potentially need post-mastectomy radiotherapy not to have immediate reconstruction but rather delay until the completion of radiotherapy. An acceptable alternative is delayed immediate reconstruction, where the tissue expander is used but deflated prior to radiotherapy delivery before re-expansion. I would prefer patients to have an autologous flap as the complication rates are lower following radiotherapy.