Reconstruction of the breast conservation deformity

Abstract

The era of breast conserving treatment of early-stage breast carcinoma has created reconstructive challenges for the plastic surgeon. Although good to excellent cosmetic outcomes occur in the majority of patients, a significant number could benefit from additional reconstructive measures. Because of the need for continuing surveillance following breast-conserving therapy, estimated at 5-10% after fifteen years, plastic surgeons should choose techniques that do not interfere with the detection of recurrent breast carcinoma. Myocutaneous flaps-in particular, the latissimus dorsi and transverse rectus abdominis-have fulfilled the reconstructive needs of these patients by providing well-vascularized soft tissue. Postoperative radiological evaluation has demonstrated that these flaps are radiolucent, unlike breast implants that can obscure accurate mammographic interpretation.Myocutaneous flaps have been used for both immediate and delayed reconstruction of post-breast conservation deformities. The delayed approach offers the benefit of an established contour deformity that usually involves cutaneous, parenchymal, and nipple-areolar components. Moderate overcorrection of the defect has been advocated in anticipation of ongoing postradiation wound contraction and fibrosis. Immediate reconstruction of lumpectomy and partial mastectomy defects permits wider initial excision of the breast lesion, but can be compromised by positive histological margins. Long-term results suggest stability of the aesthetic outcome following reconstruction of delayed deformities.

Keywords: Reconstruction; breast; conservation; deformity.

Figure 1

(A) Preoperative view of a 56-year-old woman who had excision of right nipple-areolar complex and quadrantectomy for breast cancer. (B) Result 1 year after surgery following reconstruction of the partial mastectomy defect with an ipsilateral midabdominal transverse rectus abdominis myocutaneous flap.

Figure 2

(A) Preoperative view of a 37-year-old woman with right breast loss of volume and tethering dislocation of nipple-areolar complex. (B) Postoperative view 10 years after reconstruction with a right latissimus dorsi myocutaneous flap. (C, left side) Preoperative mammographic image on left demonstrates breast conservation defect with volume loss and increased opacification of the breast caused by scar tissue. (C, right side) Postoperative mammographic appearance after placement of latissimus dorsi myocutaneous flap (enclosed by wire). The flap has restored breast volume and contour, and the flap appears as fibrofatty tissue radiologically.

Figure 3

(A) Preoperative view of a 37-year-old female with breast conservation defect characterized by nipple-areolar retraction, significant parenchymal volume loss, and skin stigmata with discoloration and telangiectasia. (B) Preoperative close-up view of the left breast conservation defect. (C) Appearance of the patient 1 year following reconstruction of the left breast conservation deformity with a left latissimus dorsi myocutaneous flap. No implant was placed in the left, but a subpectoral breast augmentation was performed in the right.

Figure 4

(A) Preoperative view of a 48-year-old woman with a lateral breast defect after breast conservation. The patient developed restricted range of motion of the left shoulder following radiation therapy. (B) Appearance of the patient 1 year after surgery. Range of motion at the left shoulder was improved after reconstruction of the breast conservation defect with a left latissimus dorsi myocutaneous flap. (C) Postoperative view 1 year after reconstruction. (D) Postoperative view 15 years after reconstruction.