Role of the General Surgeon in Breast Reconstruction

Breast cancer is an extremely emotional topic because of its anatomic location and the importance of the female breast in today’s society. Therefore, it is imperative for surgeons performing breast surgery to have a basic understanding of which patients are candidates for breast reconstruction and of the reconstructive options. Most patients start their inquiry about breast reconstruction with the surgeon who will be performing the mastectomy. They might ask, “What will it look like when you are done?” or “Will I have to live without a breast?” It is at this point that a general surgeon greatly influences a woman’s decision to pursue breast reconstruction.

Although the reconstructive surgeon goes into detail about the surgical options, risks, and expected outcomes, ablative surgeons must be prepared for at least a basic discussion with patients. Whether breast implants versus autogenous tissue will be used, where the scars will be, and how long the recovery will take are all questions that most patients want answered. The decision about whether they undergo breast reconstruction can be influenced by the bias of ablative surgeons. Oncologic surgeons are trained to place priority on ablation of the tumor; however, care standards now dictate that we also be sensitive to the resulting deformity. Only through a close alliance between the surgical oncologist and reconstructive surgeon can the patient’s emotional, physical, and oncologic needs be addressed.

History

In the late 1800s, the prognosis of patients with breast cancer was poor. Notable surgeons such as Volkmann, Czerny, and Billroth reported local recurrence rates ranging from 52% to 85%. Within 2 decades of these reports, William Halsted presented his successful treatment of breast cancer, with only a 6% recurrence rate. The halstedian theory of breast cancer treatment would remain the mainstay of breast cancer surgery for the next 60 years. He believed that “the slightest inattention to detail and or attempts to hasten convalescence by such plastic operations as are feasible only when a restricted amount of skin is removed may sacrifice his patient to the disease.” So, concerned with the possibility of inadequate skin excision, Halsted went on to say that “To attempt to close the breast wound more or less regularly by any plastic method is hazardous, and in my opinion, to be vigorously discounted.” Therefore, true attempts at breast reconstruction would have to wait for almost 50 years.

Despite Halsted’s condemnation of reconstructive procedures, it was recognized that the sizable defects left after this radical surgery did need to be closed. Although primary closure was often used, skin grafting of larger wounds was acceptable. Even though plastic procedures had been reported by Legueu and Graeve of France and Warren of the United States, these were merely chest wall closure techniques and not true breast mound reconstructions.

The first attempt at true breast reconstruction occurred in 1895, when Vincent Czerny transplanted a large lipoma from his patient’s flank to the mastectomy site. In recounting this case, Dr. Robert Goldwyn noted that 1 year after surgery, the patient was doing well and had good breast symmetry. In this particular case, the mastectomy was performed for fibrocystic disease and not cancer. Tansini described the first use of the latissimus dorsi myocutaneous flap in 1906. Unfortunately, this remarkable operation would not gain acceptance for another 70 years.

In 1942, Sir Harold Gillies of England started using a tubed pedicle technique of breast reconstruction. In this operation, he would “waltz” a flap from the abdomen to the chest to reconstruct the breast. Although this technique was successful, the multiple procedures and prolonged treatment course precluded its widespread application.

Since approximately 1970, many advances in reconstructive surgery have occurred and been applied to breast reconstruction. The development of breast implants was the first of these revolutions. In 1963, the silicone breast implant was introduced for breast augmentation and was quickly adopted for breast reconstruction. In 1963, Cronin and Gerow ¹ presented a series of patients who received implants for reconstruction of mastectomy defects. For the first time, the plastic surgeon had a procedure that could simulate the missing breast without the need for multiple procedures and a prolonged treatment course. In many ways, it was the simplicity and safety of breast implants that ignited interest in breast reconstruction. By the later 1970s, reconstruction was being performed immediately after breast ablation.²^–⁴

The development of muscle, musculocutaneous, and fasciocutaneous flaps and microsurgical transplantation has had a tremendous impact on breast reconstruction. The ideal material to reconstruct any defect is similar to tissue. Until the early 1970s, such tissue was available only in limited quantities for breast reconstruction. The landmark work by Manchot ⁵ on vascular territories of the body was rediscovered, and surgeons were then able to exploit this basic knowledge to design flaps based on the axial patterns of named blood vessels. These technical developments allowed surgeons to rearrange tissues reliably and more precisely reconstruct all types of defects, including those of the breast.⁶

Patient Selection

Women have a number of reasons for choosing to undergo breast reconstruction, including no need for an external prosthesis, fewer limitations with regard to clothing, regaining femininity, and feeling whole again. Others choose not to undergo reconstruction because they feel too old for the procedure or are afraid of complications.^7,⁸ Given the myriad of options in breast reconstruction, the surgery should be tailored to the patient’s wishes as well as her underlying health. There are a small number of relative contraindications to breast reconstruction. Extreme age, severe cardiovascular disease or other comorbidities, extreme obesity, and advanced breast disease are possible reasons why breast reconstruction may not be reasonable.

Often, women are faced with the choice, in early disease, of breast conservation therapy (BCT) versus mastectomy. Studies have shown equivalent survival outcomes when comparing the modalities of BCT with radiation and mastectomy. These decisions are often made in conjunction with the ablative surgeon. Patient satisfaction with these two modalities is varied. Pusic and colleagues ⁹ have surveyed women who underwent lumpectomy/XRT, mastectomy, and mastectomy with reconstruction. Similar to Reaby’s report,⁷ women who chose reconstruction were younger, white, and more educated. Interestingly, comfort with nudity was much lower in the mastectomy-alone group and quality of life varied with age. Younger women (<55 years) were least happy with mastectomy alone, whereas those older than 55 years were least satisfied with lumpectomy. Ultimately, the choice is that of the breast cancer patient and must be individualized.

After the advent of BCT, many women chose this option to preserve as much of their native breast as possible. The current paradigm has shifted, and more women are choosing to undergo mastectomy. This shift is multifactorial and includes dissatisfaction with the cosmesis of BCT–external radiation therapy (XRT) breasts, skin preservation mastectomies (nipple-sparing and areolar-sparing), improved reconstructive options (silicone gel prostheses and perforator flap reconstructions), genetic testing for BRCA-1 and BRCA -2 genes, necessitating bilateral mastectomies, increase in contralateral prophylactic mastectomy, and bilateral reconstruction in younger women. In addition, women who are now often diagnosed at younger ages, with higher lifetime risks, may have more aggressive disease or multifocal tumors.

Timing

The timing of breast reconstruction after mastectomy has progressed from delayed to immediate because of advances and refinements in breast reconstructive techniques and recognition of beneficial psychological effects.^7,^9,^10,¹² Because studies have shown a psychological benefit, cost-effectiveness, cosmetic advantage, and no increased risk for complications or oncologic risk with immediate breast reconstruction, it has become the preferred timing of reconstruction. In 1990, the American Society of Plastic and Reconstructive Surgeons reported that members performed 38% immediate versus 62% delayed reconstructions. In a more recent study, 75% of reconstructions were performed immediately.¹³

Because most local tumor recurrences are in the skin and/or subcutaneous adipose tissue or in the axilla, there are few reasons to delay reconstruction. Therefore, immediate reconstruction has become commonplace in America.¹⁴ It affords psychological benefits to women and is the opportune time to preserve the normal footplate of the breast—most importantly, the inframammary fold. This can be more difficult in a delayed reconstruction setting. Skin flaps are also more pliable in the immediate setting. Currently, most women with stage I or II cancer are candidates for immediate reconstruction. There are caveats to this with certain chemotherapeutic agents and the need for adjuvant radiotherapy, in which immediate reconstruction is not possible. These can interfere with postoperative healing and aesthetic outcome, respectively.

One must also consider, however, the possibility of complications with immediate reconstruction. In patients in whom reconstructions have complications such as delayed wound healing, infection, mastectomy flap loss, and flap necrosis, the initiation of chemotherapy and radiation therapy may require delay, and thus compromise, in cancer treatment. All these must be considered by the ablative and reconstructive surgeons, as well as the patient, to determine the appropriate timing of reconstruction.

Procedure Selection and Surgical Planning

The options for surgical breast reconstruction are varied and include partial and total reconstruction. Total breast reconstruction involves two common modalities, the use of an expander or implant, autologous tissue, and some combination of the two. Any of these procedures must not delay adjuvant cancer therapies. The most common procedures performed are the following (Box 37-1):

• Tissue expander placement, with later exchange for an implant

• Immediate permanent implant placement

• Latissimus dorsi with implant

• Autologous tissue (pedicled)

• Autologous tissue (free)

The choice among these therapies must take into account the need for skin resection, adjuvant radiation therapy, patient size and aesthetic desires, and activity level. Consideration of the opposite breast, and of available donor tissue, must be determined. Ideally, reconstructive surgeons would merely be filling the empty space left after removal of the gland, with preservation of the normal footplate of the breast. This is not always the case. Usually, except for advanced and inflammatory disease, some version of skin-sparing mastectomy can be performed. Breast surgeons also offer nipple- and areolar-sparing mastectomies. These allow for more aesthetically pleasing reconstructions because they confine the scar to the area around the skin paddle of a flap, if used. There is no increased cancer risk or recurrence with skin-sparing mastectomy, as long as the skin flaps are not too thick. Conversely, the thickness of the skin determines flap survival, and very thin flaps often become necrotic. In large-breasted women, the skin incisions for mastectomy may be modified to allow easy access for the general surgeon and the ability to have scar symmetry for the reconstructive surgeon. Breast reduction patterns can be used for the mastectomy, as well as the contralateral symmetry procedure.

Breast reconstruction is more than just providing a mound on the chest wall. Of utmost importance is the ability to create symmetry. Nice reconstructions can be a great disappointment if they do not match the contralateral native breast. For the most part, autologous reconstruction provides better symmetry. This is less of an issue in the case of bilateral reconstruction. In planning reconstructions, one must consider not only the size and shape of the opposite breast, but also the position on the chest wall, location of the inframammary fold, height, size, and color of the nipple-areolar complex, and amount of breast ptosis.

Implant-Based Reconstructions

Implant reconstructions are performed in those women who have a reasonable amount of good-quality skin after mastectomy, enough to cover an implant completely and provide a natural shape. They are advantageous in that they are relatively quick procedures, with minimal morbidity to the patient. Implant reconstruction is best used for a bilateral reconstruction because it is the best opportunity for symmetry. With implant-only reconstructions, it is difficult to mimic the natural ptosis and contour of the contralateral breast, except in the cases of young women with relatively small, youthful-appearing breasts (Box 37-2).

Initially, these reconstructive procedures were performed with placement of the implant in the subcutaneous pocket. This fell out of favor because of visible rippling of the implant beneath a thin layer of skin and a greater complication risk of capsular contracture. Currently, these implants are placed in a submuscular pocket beneath the pectoralis major. Some surgeons provide for full muscle coverage, with the assistance of the serratus anterior and rectus abdominis fascia inferiorly. Others provide coverage of the inferior pole of the implant with bioprosthetic material (e.g., human, porcine, bovine dermal allografts) to help create a natural inframammary fold and contoured reconstruction and provide an additional layer between the implant and inferior mastectomy skin flap. This material is sutured to the pectoralis major muscle superiorly and then inferiorly to the previously marked or designated inframammary fold (Figs. 37-1 and 37-2).^13,^15,¹⁶ Either method helps fix the pectoralis major and keeps it from migrating superiorly, exposing more of the implant.

FIGURE 37-1 Schematic representation of implant position, pectoralis position, and chest wall. The pectoralis muscle cannot cover the inferior pole of the breast; thus, bioprosthetic material is needed in the area of greatest expansion.

(Breuing KH, Warren SM: Immediate bilateral breast reconstruction with implants and inferolateral AlloDerm slings. Ann Plast Surg 55:232–239, 2005.)

FIGURE 37-2 Schematic representation of chest wall, breast, pectoralis muscle, bioprosthetic sling, and implant. Bioprosthetic material is sutured to the inferior border of the pectoralis muscle superiorly, the inframammary fold inferiorly, and curved laterally along the chest wall to re-create the footprint of the breast for expansion.

(Breuing KH, Warren SM: Immediate bilateral breast reconstruction with implants and inferolateral AlloDerm slings. Ann Plast Surg 55:232–239, 2005.)

Often, these forms of reconstruction are begun with placement of a tissue expander at the time of mastectomy. This is to allow for little stress on the tenuous mastectomy flaps initially or for progressive stretching of the skin to place a larger implant than would have been safe at the time of mastectomy. Expanders are silicone shell prostheses that have an integrated or remote port for the injection of saline in the clinical setting. Most surgeons expand the skin to a slightly larger size to provide for a large pocket with some ptosis. There is a period of 4 to 8 weeks prior to exchange of the expanders for implants to allow for maturation of the capsule and limit the rapid shrinkage of expanded skin.

In general, implant-based reconstructions provide for a round-shaped, youthful breast mound without ptosis (Fig. 37-3). Some would refer to this as less natural. It requires multiple clinic visits to provide for expansion and then a subsequent procedure to place the permanent implants, which requires a time commitment from the patient. Over time, implant reconstructions tend to change because of the effects of gravity, the body’s response to foreign objects (capsule formation), and aging of the implants themselves. This occurs linearly with time, so that 86% of women are pleased with their results at 2 years versus 54% at 5 years.¹⁷