Breast Reconstruction after Mastectomy

Abstract

Breast cancer is the leading cause of cancer death in women worldwide. Its surgical approach has become less and less mutilating in the last decades. However, the overall number of breast reconstructions has significantly increased lately. Nowadays, breast reconstruction should be individualized at its best, first of all taking into consideration not only the oncological aspects of the tumor, neo-/adjuvant treatment, and genetic predisposition, but also its timing (immediate versus delayed breast reconstruction), as well as the patient's condition and wish. This article gives an overview over the various possibilities of breast reconstruction, including implant- and expander-based reconstruction, flap-based reconstruction (vascularized autologous tissue), the combination of implant and flap, reconstruction using non-vascularized autologous fat, as well as refinement surgery after breast reconstruction.

Keywords: DIEP flap; autologous fat grafting; breast cancer; breast implants; breast reconstruction; mastectomy.

Figure 1

The 43- and 63-year-old patients after modified radical mastectomy of the left breast (A), respectively, of both breasts (B). Indication for autologous reconstruction with a microvascular flap, particularly if skin and fat excess is available and adjuvant radiotherapy has been performed.

Figure 2

A 58-year-old patient before skin-sparing mastectomy for multifocal cancer of the left breast (A). Four years after primary reconstruction of the left breast using an implant in a subpectoral plane to cover the upper half of the implant and a resorbable mesh to prevent cranialization of the partially detached pectoralis major muscle, as well as reconstruction of the nipple–areolar complex (star flap for the nipple and tatoo of the nipple and neo-areola). Note the almost symmetric size and contour of both breasts (B).

Figure 3

Typical donor site for abdominal flap-based breast reconstruction. A 57-year-old patient before (A) and 4 years after (B) harvesting a microvascular deep inferior epigastric perforator (DIEP) artery flap from the abdominal region. Note the adipocutaneous excess cranially and distally of the umbilicus, the almost invisible scar at the umbilicus and the suprapubic region, as well as the significantly improved abdominal contour [profile view (A,B)]. The reconstructed breast of this patient is shown in Figure 6.

Figure 4

Typical donor site for myocutaneous latissimus dorsi flap-based breast reconstruction. A 36-year-old patient before (A) and 2 years after secondary reconstruction of the left breast using a pedicled myocutaneous latissimus dorsi flap (B). The skin island is harvested along the posterior axillary line. Note the well concealed scar (usually in the bra-line) that does not interfere with the back of the patient, yet skin and muscle harvesting result in a slight contour deformity of the periscapular region [arrow; (B)]. The reconstructed breast of this patient is shown in Figure 5.

Figure 5

A 36-year-old patient 3 years after modified radical mastectomy of the left breast and adjuvant radio-chemotherapy. Note the oblique scar and rather large skin envelope in a thin patient (A). Two years after secondary reconstruction of the left breast using a pedicled myocutaneous latissimus dorsi flap without implant and reconstruction of the nipple–areolar complex (star flap for the nipple and tatoo of the nipple and neo-areola). Note the almost symmetric neckline and the slight volume loss of the lower pole of the breast resulting in contour deformity (B). The donor site of this patient is shown in Figure 4.

Figure 6

A 57-year-old patient 2 years after modified radical mastectomy of the left breast and adjuvant radio-chemotherapy. Note the lack of skin and volume (A). Four years after secondary reconstruction of the left breast using a microvascular deep inferior epigastric perforator (DIEP) artery flap from the abdominal region and reconstruction of the nipple–areolar complex (star flap for the nipple and tatoo of the nipple and neo-areola). Note the almost symmetric size and contour of both breasts without corrective surgery of the non operated contralateral breast (B). The donor site of this patient is shown in Figure 3.

Figure 7

A 58-year-old patient 2 years after modified radical mastectomy of the left breast, adjuvant radio-chemotherapy, and secondary expander–implant-based reconstruction. The patient developed a capsular contracture Baker grade IV with a hard, deformed, and painful breast fixed to the thoracic wall (A). One year after implant removal, radical capsulectomy and secondary reconstruction of the left breast using a microvascular deep inferior epigastric perforator (DIEP) artery flap from the abdominal region. Note the contour deformity in the neckline and upper pole region of the breast resulting from partial fat necrosis of the flap (B). Approximately 1.5 years after refinement of the contour deformity using two sessions of autologous fat grafting. Note the almost symmetric size and contour of both breasts (C).