The decision making process for women diagnosed with breast cancer or for women who are at high risk due are confronted with a multitude of decisions. For women with breast cancer, eradication of the tumor is first and foremost to ensure a cancer free survival. For women at risk for developing breast cancer, the issues are focused on prevention. There are several factors that can influence one’s decision to proceed with reconstruction that include breast cancer stage, need for adjuvant therapy, as well as one’s physical and mental status. Plastic surgeons and breast surgeons should provide information regarding the types of mastectomies performed (skin sparing versus nipple sparing), therapeutic versus prophylactic, reconstructive options (prosthetic devices versus autologous tissue versus oncoplastic), possibility of radiation therapy (RT), postoperative recovery, and adverse events.

Breast Reconstruction Options

Current statistics in the USA demonstrate that nearly 50% of women that have a mastectomy will choose to proceed with reconstruction. This percentage may be different in other countries. Breast reconstruction can be performed immediately following the mastectomy or on a delayed basis. Reconstructive options can be divided into three types: prosthetic, autologous, and oncoplastic. Prosthetic reconstruction is a relatively simple operative procedure and is associated with a shorter postoperative recovery. Autologous reconstruction is a more complicated procedure with a longer recovery period. Oncoplastic surgery includes partial mastectomy with tissue rearrangement. The decision as to which to choose will be based on factors related to the patient, surgeon, and cancer itself.

Prosthetic Reconstruction

There are two accepted methods by which prosthetic reconstruction is performed that include direct-to-implant (DTI) and 2-stage. With DTI, a permanent implant is inserted immediately following the mastectomy and with the 2-stage, a tissue expander is first inserted to stretch or preserve the post mastectomy skin followed by a permanent implant several months later. Adjunct material such as acellular dermal matrix and autologous fat grafting are often used to improve outcomes. Shaped or round silicone gel implants are safe, effective, and aesthetically preferred. In the USA, the two-stage technique is preformed most often because it will provide another opportunity to optimize breast contour and position. It is the goal of all surgical procedures to provide results that are predictable and reproducible and ultimately result in high patient satisfaction.

Autologous Reconstruction

The other principle method of breast reconstruction following mastectomy is to use a woman’s own tissues. A variety of flaps are currently available that minimize donor site morbidities and maintain high aesthetic quality. Flaps that include skin and fat only are usually referred to as perforator flaps, e.g. deep inferior epigastric perforator flap (DIEP); whereas, flaps that include muscle are referred to as musculocutaneous flaps (transverse rectus abdominis musculocutaneous (TRAM) or latissimus dorsi). Flaps are derived from virtually all areas of the body that include the abdomen, posterior and lateral thorax, gluteal region, as well as the medial and posterior thigh. Given the diversity in flap characteristics proper evaluation and patient selection is important. The lower abdominal region has become the preferred donor site for the majority of autologous breast reconstruction procedures.

Oncoplastic Surgery

Oncoplastic surgery represents the most recent option in the reconstructive armamentarium of plastic and breast surgeons. This option is frequently considered in women who require a large resection of breast tissue in order to complete their breast cancer resection rather than total mastectomy. The principle behind oncoplastic surgery is to prevent or minimize any contour abnormality following tumor removal. This may be in the form of a mastopexy, breast reduction, or by using a flap. The best candidates for oncoplastic surgery are usually women with larger breasts in whom the lumpectomy defect can be easily corrected using reduction mammaplasty techniques. In women with smaller breasts, adjacent breast tissue rearrangement may not be possible and therefore distant tissues such as the latissimus dorsi flap are considered.

Bibliography

1. Endara M, Verma K, Chen D, Nahabedian MY, Spear SL. Breast reconstruction following nipple spring mastectomy: a systematic review of the literature with pooled analysis. Plast. Reconstr. Surg. 132, 1043 – 1054 (2013).

2. Nahabedian MY. Breast reconstruction: a review and rationale for patient selection. Plast. Reconstr. Surg. 124, 55 – 62 (2009).