Breast Reconstruction
Breast reconstruction is an integral part of the surgical treatment of breast cancer. Reconstructive options are part of the discussion with a patient if mastectomy is being considered. It is a central component of the discussion if prophylactic mastectomy is being considered.
The options for reconstruction are
- autologous tissue reconstruction
- reconstruction with a subpectoral implant or
- a combination of both.
Reconstruction can be performed immediately or can be delayed until oncologic treatment is complete. Tissue options include using the latissimus dorsi muscle or the transverse rectus abdominus myocutaneous (TRAM) lap, comprising skin, fat and muscle transferred from the abdominal wall.
Tissue flaps can be either pedicled or “free” with a microvascular anastomosis.
Implants are usually placed in a subpectoral position after a pocket has been fashioned and progressively enlarged with a tissue expander. Now most mplants are saline implants, following concerns about the safety of siliconeilled devices. Recently, the moratorium on silicone implants has been lifted, and they are gaining favor, as they have been deemed safe and certainly are capable of achieving a better cosmetic result than saline implants. Subsequent nipple reconstruction can result in an excellent cosmetic outcome.
Immediate reconstruction with tissue generally gives the best cosmetic result and can have psychological benefits.
It is now possible to remove the breast tissue with a very small incision around the nipple (skin-sparing mastectomy), greatly facilitating the quality of the reconstruction by minimizing evident scars. The skin-sparing mastectomy relies on improvements in fiberoptic illumination technology and s gaining popularity. Breast cancer is rarely a disease that involves the skin; therefore, leaving considerable skin behind will have little impact on local control rates.
Patrick I. Borgen and Bruce Mann
Breast conservation therapy for invasive carcinoma of the breast. Current Problems in Surgery 1995; 33:189-256.
References
- Veronesi U, Saccozzi R, Del Vecchio M et al. Comparing radical mastectomy with quadrantectomy, axillary dissection, and radiation therapy in patients with small cancers of the breast. N Engl J Med 1981; 305:6-11.
This is the landmark report of the first randomized prospective trial of breast-conservation therapy. - Fisher B, Bauer M, Margolese R et al. Five-year results of a randomized clinical trial comparing total mastectomy and segmental mastectomy with or without radiation in the treatment of breast cancer. N Engl J Med 1985; 312:665-73.
This is the first report of the major North American trial of breast-conservation therapy from the NSABP. - Borgen PI, Heerdt AS, Moore MP et al. Breast conservation therapy for invasive carcinoma of the breast. Current Problems in Surgery 1995; 33:189-256.
This is a review of all aspects of breast-conservation therapy. - Fisher B, Costantino J, Redmond C et al. Lumpectomy compared with lumpectomy and radiation therapy for the treatment of intraductal breast cancer. N Engl J Med 1993: 1581-6.
This is the major trial of conservative therapy for DCIS - Adair F, Berg J, Joubert L et al. Long-term follow-up of breast cancer: the 30-year report. Cancer 1974; 33:1145-50.
This is an older report from the days before adjuvant therapy that demonstrates the effectiveness of surgery in node-positive disease. - Fisher B, Redmond C, Fisher E et al. Ten year result of a randomized clinical trial comparing radical mastectomy and total mastectomy with of without irradiation. N Engl J Med 1985; 312:674-81.
This is a very influential trial that showed that less-extensive surgery had similar results to radical mastectomy. - Warmuth MA, Bowen G, Prosnitz LR et al. Complications of axillary lymph node dissection for carcinoma of the breast: a report based on a patient survey. Cancer 1998; 83:1362-8.
This report gives a good idea of the range of complications after axillary dissection.