The suspension technique to avoid the use of tissue expanders in breast reconstruction

BACKGROUND: Immediate or delayed breast reconstruction is usually performed using expansion techniques or pedicled or free flaps. The suspension technique hereby described can reduce the number of surgical stages, as well as donor-site sequelae. TECHNIQUE: The authors describe a new technique of breast reconstruction with implants using a nonabsorbable mesh to create a superior abdominal cutaneous flap, which contributes to the skin envelope of the reconstructed breast. The advantage of this technique is the opportunity to use immediately a definitive prosthesis also in cases requiring a mastectomy with the resection of a large amount of skin, consequently reducing the indications of tissue expanders or myocutaneous flaps. RESULTS: We performed the "suspension technique" in 67 cases of immediate reconstruction and in 6 cases of delayed reconstruction. No further surgery under general anesthesia was necessary in 56 patients (76.7%). In 14 cases (19.2%), a second operation under general anesthesia was necessary for implant replacement, capsula revision, and nipple and areola (NAC) reconstruction. In 3 cases (4.1%), implant removal was necessary due to implant exposition or infection. In 33 patients, only NAC reconstruction was performed under local anesthesia. In our series, capsula contracture was graded as Baker I in 24 cases, grade II in 16 cases, grade III in 9 cases, and grade IV in 1 case. Breast symmetry, patient's satisfaction, and surgeon cosmetic evaluation were respectively scored 7.56, 7.75, and 7.60 (range from 1 to 10). CONCLUSION: In conclusion, this technique can be applied in cases requiring a large skin resection at the time of mastectomy and refusing a reconstruction with myocutaneous flaps or a second surgery, necessary if a reconstruction with tissue expanders is planned.     

Brustrekonstruktion mit gestielten Lappen

It is important for women with breast cancer undergoing mastectomy to make an informed decision about the options for breast reconstruction and to be provided with information about the techniques, advantages and disadvantages. After modified radical mastectomy breast reconstruction involves replacement of breast skin and volume and after skin-sparing mastectomy only the volume must be reconstructed. The most commonly used surgical techniques are expander implant reconstruction, latissimus dorsi myocutaneous flaps with or without implants and the use of lower abdominal tissue. Currently, the pedicled transverse rectus abdominis myocutaneous (TRAM) flap is the standard method for autologous breast reconstruction after mastectomy and thoracic wall irradiation. In recent years microsurgical perforator flaps have gained in popularity because of the lower morbidity.     

Breast reconstruction following mastectomy for cancer.

Breast reconstruction following mastectomy for cancer is a feasible procedure. The selection of the proper type of mastectomy should be the decision of the cancer surgeon. However, with the advent of modified mastectomies, the use of fewer primary skin grafts, and the preservation of all or part of the pectoralis major muscle, breast reconstruction has become more satisfactory. Since many women adjust poorly to mastectomy, the chance for reconstruction offers hope for a fuller life. Reconstruction of the postmastectomy cancer patient can be accomplished in three basic steps: 1) An adequate breast mound can be constructed with a prosthesis. A flap may be used if the skin cover is inadequate. 2) The size and shape of the remaining breast can be adjusted to obtain symmetry. 3) The nipple-areola complex can be reconstructed if the patient desires. Correction of the infraclavicular and axillary defects may be required. The techniques employed in 14 patients are presented.     

Surgical strategy,methods of reconstruction,surgical margins and postoperative complications in oncoplastic breast surgery

Background

Oncoplastic breast surgery is an evolving discipline in the surgical treatment of breast cancer aimed to improve the outcome.

Methods

Oncoplastic breast surgery was performed between January 2008 and December 2010 on 72 women with 74 breast cancers selected from a population of 1,018 primary breast cancer patients. Careful preoperative planning revealed the possibility of partial breast reconstruction with volume reduction, volume displacement or volume replacement depending on breast size as well as tumour size and location. Data were registered consecutively.

Results

The surgical plan was successful in all but one case, where a mastectomy had to be performed during the primary surgery. In 53 cases, a contralateral mammoplasty was performed during the operation to achieve symmetry. During the follow-up period until November 2011, only one patient needed corrective surgery. Final histopathological examination indicated that seven cases required extended resection and three cases required a mastectomy. Five patients experienced delayed wound healing, although complications requiring further surgery occurred for the reconstructed breast in four cases, the contralateral breast in three cases and the axilla after exaeresis in two cases because of haematoma. Such complications led to slight delay in adjuvant therapy for four patients.

Conclusions

This study demonstrates that it is feasible to implement oncoplastic breast surgery into daily clinical practice as a supplement to conventional breast cancer surgery. As such, oncoplastic breast surgery may provide a markedly better outcome than breast-conserving surgery in terms of shape and symmetry without compromising the surgical margins. Level of Evidence: Level IV, prognostic/risk study.     

Impact of immediate reconstruction on the local recurrence of breast cancer after mastectomy

The incidence of local recurrence of breast cancer in women who underwent mastectomy with or without reconstruction was examined. All female mastectomy patients were followed-up in a 10-year retrospective review. Groups consisted of patients who had mastectomy, mastectomy with immediate reconstruction, or delayed reconstruction. Reconstruction was performed using prostheses, latissimus dorsi musculocutaneous flaps with or without implants, or transverse rectus abdominis musculocutaneous flaps. Charts were reviewed for local breast cancer recurrence. Statistical analysis was performed using Pearson's chi-square and analysis of variance. Of the 1,444 mastectomies performed from 1988 to 1997, 1,262 breasts (87%) were not reconstructed, 182 (13%) were reconstructed, 158 (87%) were immediately reconstructed, and 24 (13%) were reconstructed later. There were no recurrences in the delayed reconstruction group, two recurrences (1.3%) in the immediate reconstruction group, and nine recurrences (0.7%) in the mastectomy without reconstruction group (p=0.746). Analyses of an additional time period from 1992 to 2000 yielded similar results. There is little relationship between local recurrence of breast cancer after mastectomy and reconstruction.     

Rationale for elective contralateral Mastectomy with immediate bilateral reconstruction

Background: Women with breast cancer treated by mastectomy with immediate breast reconstruction can get exceptionally good results if the reconstruction is performed with autogenous tissue using the transverse rectus abdominis myocutaneous (TRAM) flap. Bilateral reconstruction with TRAM flaps is also possible, but only if both breasts are reconstructed at the same time. To avoid the possibility of subsequently developing contralateral malignancy and having to undergo assymetrical reconstruction with a different technique, some patients have chosen the alternative of bilateral mastectomy with bilateral immediate reconstruction. This is only reasonable if the incidence of failure in bilateral breast reconstruction is very low. Methods: We prospectively studied reconstructive outcomes in 100 patients who had breast cancer and who underwent bilateral mastectomy and reconstruction (using implants as well as TRAM flaps). We also reviewed the histologic findings in 88 prophylactically removed high-risk breasts. Results: Successful outcomes were initially achieved in 95 patients; of the 5 failures, two were successfully reconstructed with alternative techniques for an overall success rate of 97%. Of the 63 patients reconstructed with bilateral TRAM flaps, all but one (98%) were successful on the first try. TRAM flap reconstructions were significantly more likely to be successful than were those based on implants (p=0.05). Previously unsuspected invasive cancer was found in 3 patients (3.4%), whereas carcinoma in situ was found in 5 patients (5.7%) and in another 18 patients (20%) cellular atypia was present. Conclusions: Bilateral breast reconstruction has a low incidence of failure, particularly if TRAM flaps are used. For selected patients, elective contralateral mastectomy with immediate bilateral reconstruction is a reasonable treatment alternative provided that the necessary expertise is available and the patients clearly understand the risks.The results of this study were presented at the 46th Annual Cancer Symposium of The Society of Surgical Oncology, Los Angeles, California, March 18–21, 1993.     

腹壁下动脉穿支皮瓣在双侧乳腺癌改良根治术后乳房再造中的应用

目的 总结采用腹壁下动脉穿支游离皮瓣再造双侧乳房的经验。方法 2004年6月至2005年5月,对3例双侧乳房改良根治术后的患者,应用DIEP皮瓣行二期乳房再造术。结果 3例患者6个皮瓣均成活。随访3个月以上,双侧再造乳房双侧对称,外形满意。未见腹壁疝和腹壁膨出发生。结论 选用DIEP皮瓣游离移植再造乳房,是乳腺癌改良根治术后恢复双侧乳房外形的一种理想方法。     

Skin expansion before breast reconstruction with the superior gluteal artery perforator flap improves aesthetic outcome

To improve the aesthetic outcome in the reconstructed breast and in the flap donor area, the technique of skin expansion in the mastectomy site was used in eight patients who subsequently underwent breast reconstruction using the superior gluteal artery perforator (SGAP) flap. The authors think that skin expansion before final reconstructive surgery provides adequate ptosis and better positioning of the flap on the chest, leading to a more natural appearance and symmetry of the reconstructed breast. Furthermore, the skin expansion reduces the amount of free flap skin required for breast reconstruction, resulting in less donor site scarring and morbidity. They present their surgical refinements to improve the aesthetic appearance of the breast reconstructed using the SGAP flap.     

Oncoplastic surgery: the evolution of breast cancer treatment

Oncoplastic surgery is an establish approach that combines conserving treatment for breast cancer and plastic surgery techniques. It allows wide excisions and prevents breast deformities by immediate reconstruction of large resection defects. The procedures are mostly useful for resection of 20-40% of the breast - a group of patients normally treated by mastectomy in the past. Four features are integral to oncoplastic breast surgery: (i) Appropriate surgery for cancer excision. (ii) Partial reconstruction to correct wide excision defects. (iii) Immediate reconstruction with the full range of available techniques. (iv) Correction of volume and shape asymmetries relative to the contra-lateral healthy breast. There are two fundamentally different approaches: (i) volume-replacement procedures, which combine resection with immediate reconstruction by using local flaps (glandular, fasciocutaneous, and latissimus dorsi mini-flaps), and (ii) volume-displacement procedures, which combine resection with a variety of different breast reduction and reshaping techniques, according to the location of the tumor. Oncoplastic surgery increases the oncological safety of breast-conserving treatment because a much larger breast volume can be excised and wider surgical margins can be achieved. Moreover, a "surgical screening" of the contra-lateral breast allows the diagnosis of occult cancers. Among oncoplastic approaches, a very unique technique is the possibility of implant use (augmentation mammaplasty) in case of quadrantectomy and simultaneous delivery of intraoperative radiotherapy to the tumor bed.     

经乳晕环形切口皮下乳腺切除与即刻腹直肌肌皮瓣再造术

目的　为完善和提高再造乳房的质量 ,使患早期乳腺癌的病人更容易接受乳房再造手术。方法　选择患乳腺导管内原位癌的病人 ,经乳晕切口活检做病理检查确立诊断 ,采用乳晕环形切口行保留乳房皮肤的乳腺皮下切除术 ,应用腹直肌肌皮瓣即刻再造乳房 ,仅以少量的肌皮瓣皮肤弥补切除的乳头、乳晕 ,在此皮瓣上再造乳头 ,经文身使乳头、乳晕色泽与健侧一致。结果　此方法再造的乳房瘢痕较少 ,且隐蔽 ,外观形态自然 ,易与健侧对称 ,保留了乳房皮肤的良好感觉 ,但手术适应证选择要严格 ,以免术后乳腺癌复发 ,术中切除乳腺需彻底但又不能损伤乳房皮肤和皮下组织 ,其过程需多专科协作完成。结论　在严格选择手术适应证的前提下 ,经多专科协作完成的该术式 ,为一更加完善的乳房再造方法     

Quantitative analysis of the reconstructed breast using a 3-dimensional laser light scanner

Postoperative cosmesis of the reconstructed breast depends on the interrelation of shape, size (volume), and symmetry. In this study, reconstructed breasts were analyzed with 3-dimensional projections generated by laser light scanning. Fifty-one cases of breast reconstruction following mastectomy (16 cases of rectus abdominis flap, 15 cases of latissimus dorsi flap, and 20 cases of tissue expansion) were evaluated 6 months postoperatively. Shape, volume, and symmetry were quantitatively evaluated. Captured images of the normal breast were mirror-reversed and superimposed on images of the reconstructed breast. Differences in the generated Moire patterns were used to quantitatively compare breasts. The method was rapid, reproducible, and accurate in comparison to thermoplaster casts. It was found that rectus abdominis flaps applied following total mastectomy and latissimus dorsi flaps applied following partial mastectomy gave the best results for their relatively low degree of asymmetry. Application of tissue expansion led to greater asymmetry and poorer overall cosmesis. In conclusion, a 3-dimensional laser light scanning system makes it possible to quantitate the cosmetic outcome following breast reconstruction.     

Factors Affecting Symmetrization of the Contralateral Breast: A 7-Year Unilateral Postmastectomy Breast Reconstruction Experience

Although a number of studies compare different techniques of breast reconstruction, information documenting the factors that affect breast symmetry after unilateral mastectomy and reconstruction seems to be scarce. A statistical analysis of 606 patients undergoing unilateral mastectomy and breast reconstruction performed during a 7 year period was undertaken in an endeavor to identify these factors. Patients were classified according to time of reconstruction, method of reconstruction, type of implant, and mastectomy type. Contralateral procedures included mastopexy, augmentation, and reduction mammaplasty. Delayed reconstruction more frequently required a symmetrization than an immediate reconstruction. The percentage of contralateral procedures was higher for implant reconstructions than for autologous reconstructions, and the type of mastectomy was significantly associated with the symmetrization procedure. The findings showed that non–skin-sparing mastectomy (non-SSM) needed symmetrization surgery more frequently than did SSM procedures. The data suggest a preoperative collaboration and case study between oncologic and plastic surgeons to apply, when possible, SSM with immediate implant breast reconstruction, resulting in fewer symmetrization procedures and the best aesthetic follow-up result. These factors need to be considered when mastectomy and reconstruction are planned in order to optimize the aesthetic result together with the development of breast surgery specialty units.     

乳癌术后的乳房再造

目的 探索乳癌根治术后3种不同乳房再造方法的最佳外观效果.方法 (1)乳癌切除Ⅱ期行扩大背阔肌肌皮瓣乳房再造.(2)乳癌切除即时腹直肌横行皮瓣乳房再造.(3)保留胸大肌乳癌切除,Ⅱ期乳房假体置入并行乳头、乳晕再造;对不保留胸大肌乳癌切除者,Ⅱ期皮肤扩张后乳房假体置入再造.结果 共计治疗12例,10例皮瓣全部成活,外观形态满意,优良率较高.2例不满意,其中1例扩张后,因局部皮肤皮下组织较薄,扩张程度不足,勉强置入140 ml乳房假体,外观形态明显偏小;另1例腹直肌肌皮瓣大部分坏死,经再次修复创面愈合,乳房再造失败.结论 乳房再造的方法选择得当,可使乳房形态更为自然.普通背阔肌皮瓣改用扩大的背阔肌皮瓣后,软组织量比前者增加1倍以上,使再造乳房与对侧相近.假体置入乳房成形后,Ⅱ期行单蒂乳头、乳晕再造,可给患者以心理和外观上的更多抚慰.     

不同方法乳房重建术的患者报告结局

乳腺癌术后乳房重建可以提高患者的自尊和健康相关的生活质量,重建方式有自体组织重建与假体重建。自体重建有不同自体组织;假体重建有一步法与二步法,假体植入物有不同类型,按重建时间分为即刻与延期重建;重建后可能需要放疗。不同重建材料、重建时机和术后放疗,都可能会对乳房重建患者的报告结局产生影响。本文就不同方法乳房重建术的患者报告结局的研究进展作一综述。     

Recent trends in breast cancer surgery in Japan

In the past ten years, extended or conventional radical mastectomies have decreased, being replaced by modified radical mastectomies (muscle-preserving mastectomies) such as Auchinoloss' operation and Patey's operation. Furthermore, limited surgeries for early cases such as partial mastectomy, lumpectomy etc. also have increased in the recent three years. The indications for these operations, the surgical techniques, postoperative functional and cosmetic problems were presented. And future problems as to partial mastectomy were also discussed. In contrast, aggressive surgery such as extensive resection of the chest wall for locally advanced breast cancer is useful as one of the therapeutic measures in the recent multidisciplinary treatments for breast cancer, in order to prolong the patient's survival and improve the quality of life. The techniques including the reconstruction using musculocutaneous flaps were also presented.     

The role of reduction mammaplasty in oncology

Background: A procedure to achieve symmetry is required in almost 50% of the cases of breast reconstruction and provides an opportunity to explore the second breast and eventually to remove any area which is suspect. The various techniques available for the symmetry procedure should be discussed according to the breast exploration required. This study analyzes the different types of reduction mammaplasty (RM) techniques, the histology and localization of contralateral tumors which allow the plastic surgeon to diagnose occult breast cancer more accurately.Method: From 1978 to 1993, 1814 patients with breast cancer underwent a mastectomy with breast reconstruction at the Gustave-Roussy Institute. A contralateral RM to achieve symmetry was performed in 440 patients.Results: Twenty (4.5%) clinically and radiologically occult breast cancers were found among the contralateral RM specimens. The relationship between the type of RM technique and incidence of occult breast cancer was not significant: 16 cases of occult breast carcinomas in 305 RM with supra-areolar pedicle and four cases from 135 RM with infra-areolar pedicle (Fisher exactp=0.21).Conclusion: Close collaboration between plastic surgeon and oncologist is required while performing a breast reconstruction in order to take advantage of the surgery of the second breast to explore the gland and to remove occult carcinomas in approximately 5% of cases. The choice of RM procedure depends usually on the shape of the breast and often the personal preference of the surgeon but this should also be planned according to the glandular area to be explored. There results underline the absolute necessity of histological examination of all the specimens removed in all kinds of breast reduction also when it is performed for purely aesthetic reasons.     

Improvement of upper extremity lymphedema after delayed breast reconstruction with an extended latissimus dorsi myocutaneous flap

Lymphedema is a common complication after mastectomy in breast cancer patients. Many treatment options are available, but no treatment results in a complete cure. We report a case of lymphedema that occurred after modified radical mastectomy in a breast cancer patient who showed objective improvement after delayed breast reconstruction with an latissimus dorsi myocutaneous flap. A 41-year-old female patient with left breast cancer had undergone modified radical mastectomy with axillary lymph node dissection and postoperative radiotherapy 12 years previously. Four years after surgery, lymphedema developed and increased in aggravation despite conservative treatment. Eight years after the first operation, the patient underwent delayed breast reconstruction using the extended latissimus dorsi myocutaneous flap method. After reconstruction, the patient's lymphedema symptoms showed dramatic improvement by subjective measures including tissue softness and feeling of lightness, and by objective measures of about 7 mL per a week, resulting in near normal ranges of volume. At a postoperative follow-up after 3 years, no recurrence was observed. Delayed breast reconstruction with extended latissimus dorsi myocutaneous flaps may be helpful to patients with lymphedema after mastectomy. This may be a good option for patients who are worried about the possibility of the occurrence or aggravation of secondary lymphedema.     

The "banked" TRAM: a method to insure mastectomy skin-flap survival

BACKGROUND: Necrosis of the skin flaps after mastectomy can be a devastating complication following immediate breast reconstruction with a TRAM flap. Skin-flap loss compromises the aesthetic result and may necessitate revisional surgery. The authors wish to present a simple and effective method to insure mastectomy skin-flap survival. METHODS: Seven patients over the last 5 years were treated with immediate breast reconstruction with a TRAM flap after skin-sparing mastectomy and had evidence of skin-flap compromise intraoperatively. These patients had their TRAM flaps "banked" under the flaps and returned to the operating room within 72 hours for definitive debridement of the skin flaps, deepithelialization, and insetting of the TRAM. RESULTS: In all cases, there was 100% survival of the skin flaps after delayed insetting. There was no skin-flap loss. No patients required additional surgery for revision. CONCLUSIONS: The banked TRAM is a simple and effective method to insure mastectomy skin flap survival if there is a question of flap viability.     

Tug 'O' war: challenges of transverse upper gracilis (TUG) myocutaneous free flap breast reconstruction

Autologous tissue microsurgical breast reconstruction is increasingly requested by women following mastectomy. While the abdomen is the most frequently used donor site, not all women have enough abdominal tissue excess for a unilateral or bilateral breast reconstruction. A secondary choice in such women may be the transverse upper gracilis (TUG) myocutaneous flap. This study reviews our experience with TUG flap breast reconstruction looking specifically at reconstructive success rate and the requirement for secondary surgery. A total of 16 free TUG flaps were performed to reconstruct 15 breasts in eight patients over a period of five years. Data were collected retrospectively by chart review. Follow up ranged from 14 to 41 months. During the follow up period, there was one (6.3%) complete flap loss in an immediate breast reconstruction patient. Four further flaps (25%) failed in their primary aim of breast reconstruction, as they required additional significant reconstruction with either deep inferior epigastric perforator (DIEP) flaps (two flaps (12.5%), one patient) or augmentation with silicone breast implants (two flaps (12.5%), one patient), giving a successful breast reconstruction rate with the TUG flap of only 66.7%. In all of the remaining reconstructed breasts, deficient flap volume or breast contour was seen. Eight flaps were augmented by lipofilling. A total of 62.5% of the donor sites had complications, namely sensory disturbance of the medial thigh (25%) and poor scar (37.5%) requiring revision. This series demonstrates a high rate of reconstructive failure and unsatisfactory outcomes from TUG flap breast reconstruction. We feel this reinforces the necessity of adequate pre-operative patient assessment and counselling, including discussion regarding the likelihood of subsequent revisional surgery, before embarking on this form of autologous breast reconstruction.     

Breast reconstruction

During the last century, breast reconstruction after mastectomy has become an important part of comprehensive treatment for patients who have breast cancer. Breast reconstruction initially was created to reduce complications of mastectomy and to diminish chest wall deformities. Now, however, it is known that reconstruction also can improve the psychosocial well-being and quality of life of patients who have breast cancer. This article reviews the techniques used for breast construction after breast surgery.