Breast Reconstructive Options

Abstract

Breast reconstructive options have evolved over the past six decades. Despite advancements in technology, improved therapeutic options, and genetic testing, women are still, unfortunately, faced with a myriad of deformities after treatments for breast cancer. In order to restore an esthetically pleasing breast mound, a careful evaluation of the patient must be taken into account. There are, generally, three components or factors that need to be considered while devising an excellent reconstructive option for a particular patient. These are: patient factors, surgeons’ factors, and oncologic factors. It is only with a detailed understanding of each one of these factors that a sound solution is arrived at. In this chapter, we will explore the various modalities of breast reconstruction available to patients. We will also demonstrate specific considerations in order to optimize an excellent outcome for our breast cancer patients.

1. Introduction

Breast cancer (BC) is the most common cancer of women in the United States and worldwide [1, 2]. The management of BC is in constant evolution. Multiple landmark studies published in the last several decades have led to a transition from a more radical surgical approach towards breast conserving surgery and less deforming mastectomies [3, 4, 5, 6, 7] (Figure 1). Similarly, the field of breast reconstruction (BR) has seen many changes in the form of new knowledge and technical advancements that have led to the development of modern reconstructive practices for restoration of a breast mound.

Figure 1.

Evolution of breast cancer surgery.

The surgical treatment of BC is best achieved in a multidisciplinary approach [8, 9, 10]. The patient typically requires the expertise of many medical and surgical specialists as part of their collaborative treatment plan. Adjuvant therapies in the form of chemotherapy, radiation therapy, hormonal therapy, biologic therapy, and psychologic therapies, may be required for optimal treatment of BC patients. For those undergoing a surgical treatment, reconstruction should be an integral part of the treatment plan as well. The goal of BR is to restore an esthetically pleasing breast mound. With many recent advancements in knowledge and surgical techniques, the ability to restore a cosmetically appealing breast utilizing BR has evolved into its modern practice.

The female breast is the most revered symbol of femininity. From physiological stand point, the breasts main function is lactation. From an anatomical perspective, they serve as a crucial part of the female body image and sexuality [11]. Breast oncologic surgery for the treatment of BC may lead to anatomic deformities with the consequence of adverse impact on the patient’s quality of life [12]. Many studies have shown the psychologic and therapeutic benefits in women who undergo BR [13]. The breast restoration experience has been shown not only to reinstate the esthetically pleasing breast but also to improve the personal body image in these women [14].

When a BC patient undergoes a surgical treatment for a tumor, it may result in breast deformities or the complete acquired absence of a breast.

With breast conserving therapy, which entails lumpectomy and radiation, several breast contour deformities and volume distortion may result from tumor excision and radiation treatment (Figure 2) [15, 16].

Figure 2.

48 year old female after lumpectomy and radiation to her right breast. Volume distortion and contour abnormality is clearly visible in the right breast compared with left.

In patients undergoing mastectomy either as a Skin Sparing Mastectomy (SSM) or a Nipple Sparing Mastectomy (NSM), the result is a patient with acquired breast absence (Figure 3). In order to offset these deformities, and optimize the surgical outcome, the patient should be informed of reconstructive options prior to undergoing the lumpectomy or mastectomy procedures. Therefore, it is absolutely imperative to involve the reconstructive plastic surgeon as part of the multidisciplinary team as soon as the diagnosis for BC is made. This will allow the patient to have access to and be carefully evaluated by the reconstructive plastic surgeon and help determine what breast restoration options are available to the patient early in the treatment process.

Figure 3.

32 year old female after right mastectomy with total acquired breast absence.

2. Options for breast cancer surgery

• Conservative treatment (lumpectomy +radiation)

  In some cases, Oncoplastic surgery.

• Mastectomy

  Modified radical, Skin Sparing, Nipple Sparing

  1. With Reconstruction

     1. Autologous Tissue

     2. Implant based reconstruction

     3. Fat grafting

  2. Without Reconstruction

• Contralateral Breast surgery

3. Considerations in breast reconstruction

There are three different factors that must be considered while choosing a BR option. These are patient related factors, Oncologic factors, and surgeon related factors. The plan must be individualized to each patient based on these factors. Furthermore, the decision process of reconstructive procedure must entail a collaborative approach between the plastic surgeon and the affected patient [17]. More specifically, the reconstructive plastic surgeon presents the available options based on the above mentioned factors, while the patient states her desires to finally arrive at the optimal breast reconstructive plan.

Patient related factors are: the age of the patient, the patient’s desires, overall health and comorbidities, previous breast or other body surgeries, smoking history, and patient anatomy. Oncologic factors involve BC history, history of radiation therapy, history of breast biopsies, tumor biological features, and the potential need for adjuvant chemotherapy, radiation therapy, biological and hormonal therapy. Surgeon related factors include the availability of a plastic surgeon to perform a particular reconstruction, and optimal facility with appropriate capabilities and ancillary staff where the surgery will be performed.

4. Who is a candidate for BR after BC surgery?

Most women diagnosed with BC are candidates for BR which is viewed as part of the healing process. Every patient, regardless of disease stage, socioeconomic status, or demographics, must be informed about options and techniques available to them. Historically, there was a concern that BR may mask locoregional recurrence or that it may compromise adjuvant treatments [18]. However, the available evidence suggest that BR does not adversely affect disease-free or overall survival and there is no significant delay in recurrent disease presentation [19]. Currently, with improved social media and internet access, there is an increase in frequency of patients who are desiring breast reconstruction after mastectomy [20].

The multidisciplinary team should review important parameters in order to obtain a complete evaluation of any particular patient (Figure 4).

Figure 4.

Breast reconstruction patient’s criteria.

There is a particular group of patients who is considered high risk based on genetic mutations. Less than 15%of all BC are associated with germline mutations [21]. The majority of hereditary breast tumors are due to mutations in BrCa1 and/or BrCa2 genes, these patients often have bilateral and multicentric disease, early-onset, and more likely to be Triple Negative (ER-, PR-, HER2-) [22, 23]. One of the most effective strategies in treating these women is the prophylactic mastectomy better defined as Risk Reduction mastectomy (RRM). This technique provided the greatest reduction in risk of BC development (around 90%) and also diminishes the anxiety and fear in these affected women [24]. As a result of that, this subset of patients can benefit from prophylactic mastectomy, and require breast reconstruction of their affected breast as well as a restoration procedure for their contralateral breast. It should be noted that contralateral RRM does not improve survival in patients without deleterious genetic mutations or lobular histology [25]. In the USA, a growing rate of bilateral mastectomy for unilateral BC is being observed. Availability of immediate BR, young age, pathogenic BrCa mutations, significant family history, and Triple Negative disease play a significant role in choosing this type of surgery. NSM plus immediate BR is nowadays considered the gold standard in this group of women [26].

5. No reconstruction

Some patients prefer not to have BR and opt for a breast prosthesis instead. The advantage of this device is not taxing the body with additional surgery other than the required oncologic procedure. The disadvantages are significant discomfort, skin irritation and rashes, and inability to wear a bathing suit or clothing comfortably. This option is reasonable for an elderly patient who is not concerned about cosmesis or a patient with many comorbidities who is not a candidate for BR.

6. Delayed reconstruction

A delayed BR is breast restoration performed at a later date as an independent separate procedure by the plastic surgeon. The patient initially undergoes the oncologic procedure with a mastectomy or breast conserving therapy. Subsequently, the patient pursues Breast reconstruction based on a collaborative approach with the plastic surgeon. This reconstructive option is ideal if there is no availability of plastic surgeon at the facility or if negative margins could not be achieved during the oncologic procedure. Once the patient is cleared from an oncologic standpoint, the BR can be pursued at a later date. Advantages include allowing time to identify a board certified plastic surgeon who will perform the reconstruction at a nearby facility as well as appropriate allotted time for oncologic treatment in terms of achieving final negative margins. The disadvantage of this approach is that by waiting, the patient endures the negative psychologic implications of not having a breast or having a deformed breast until the reconstruction is performed. In addition, with delayed reconstruction there is scarring and fibrosis that forms as part of the healing process that may impact the type of reconstruction that can be performed at a later date [27, 28].

7. Implant based reconstruction (IBR)

IBR entails using a breast implant (silicone or saline) to create a breast mound after mastectomy. The advantages of IBR are that this procedure is relatively simple, expedient, and has short recovery time. The disadvantages are implant related complications such as implant rupture, exposure, extrusion, and capsular contractures [29]. IBR can be performed in a single or two stage technique. In a single stage IBR, the plastic surgeon places the breast implant to reconstruct the breast mound at the same operation immediately after mastectomy [30]. Alternatively, IBR can be performed in two stages. This is particularly useful in cases where extra skin needs to be recruited. In this approach, a tissue expander is placed first at the time of mastectomy. The device is expanded over time on a weekly basis in the medical office. Several months later, the second stage of the procedure is performed where the tissue expander is removed and replaced with a permanent breast implant [31].

Irrespective of single or two stage implant reconstruction technique, anatomically, these devices (expander and/or implant) can be placed either above or below the pectoralis muscle. In the early period of breast reconstruction, pre-pectoral (above the pectoralis muscle) implant placement was abandoned due to high rates of capsular contracture, implant extrusion and poor esthetic results. Subsequently, the shift to subpectoral plane (under the pectoralis muscle) offered an increased coverage of the implant and less of the above implant related complications However, over the years it became apparent that submuscular implant placement is associated with chronic muscle related pain, muscle spasms, animation deformity, and reduced physical mobility. With optimization of mastectomy technique, advances in radiotherapy, use of alloplastic devices, fat grafting, and new implant designs, the prepectoral approach has undergone a revival and is now performed in many centers around the world [32].

With certain surgical advancements, oncologic surgeons are transitioning to SSM and NSM. Technological breakthrough has contributed to the availability of mesh (Human/animal/synthetic) for reconstructive support [33]. Improvements in the breast implant device characteristics have led to improved outcomes for patients undergoing IBR as well. Furthermore, due to these advances in mastectomy techniques, and the recent increase in bilateral mastectomies performed, IBR is the most common approach currently used for breast reconstruction. According to The American Society of Plastic Surgeons 2018 publication, 40% of women who underwent mastectomy had reconstruction and the most common practice in the US was immediate reconstruction (75% of the cases) of these 81% corresponded to Implant based (two-stage 68%, one stage 13% (Figures 5 and 6) [34].

Figure 5.

36 year old female with history of bilateral SSM and immediate subpectoral implant based BR. Of note she also had bilateral nipple reconstruction.

Figure 6.

28 year old female with history of BRCA gene mutation. Left: demonstrates her pre surgery (pre mastectomy). Right: patient 6 months after Bilateral prophylactic NSM with immediate prepectoral implant based BR.

8. Autologous breast reconstruction (AR)

The premise in AR is utilizing tissue such as skin, fat, and sometimes muscle from another place on the patient’s body in order to create a breast mound. AR can be performed in immediate or delayed fashion as well [35]. Many different types of flaps have been described in the literature for restoration of breast mound using patients own body tissues [36]. Some are abdominal based flaps (TRAM, DIEP, SIEA), others are gluteal based flaps (SGAP, IGAP), there are thigh based flaps (PAP, TUG) and back based flaps (LD, TDAP) [37]. Most of these flaps require a microsurgeon who is well versed in microsurgical techniques, the availability of a microscope, a well-trained surgical team in microsurgery, and a facility that can support these types of complex and delicate operations. The advantages of BR using these flaps are natural appearing results, esthetically pleasing outcome, and improved patient satisfaction [38]. The disadvantages are the need for a skilled microsurgeon, long procedure time, longer recovery period, extra scarring in the donor sites, and increased pain. Figures 7–10 show examples of Autologous Breast reconstruction.

Figure 7.

Top: 39 year female diagnosed with left breast cancer. Bottom: after Left NSM and reconstruction with abdominal based flap.

Figure 8.

49 year old female with history of right breast cancer. Patient underwent autologous reconstruction with abdominal based flap. Left: right breast reconstruction with DIEP (deep inferior epigastric perforator) flap. Right: same patient after nipple reconstruction.

Figure 9.

Left: 38 years old female diagnosed with invasive right breast cancer. Right: same patient after right NSM and reconstruction with TUG (transverse upper gracilis) flap.

Figure 10.

Patient with history of bilateral breast cancer, right invasive ductal and left lobular in situ. She is shown after bilateral SSM and immediate reconstruction with bilateral LD (latissimus Dorsi) flaps. Delayed tattooing nipple reconstruction.

9. BR with lipofilling

BR could be achieved by lipofilling (fat transfer) after mastectomy. This technique involves removing fat from certain areas in the body by way of liposuction, processing the fat cells, and transferring them to the area of absent breast. It is important to note that there is a limitation of how much fat can be injected in order for the fat cells to survive and often times this requires several sessions of fat grafting in order to obtain the desired result. Patients who undergo breast conserving therapy with lumpectomy resulting in a contour deformity or volume deficiency after excision, may benefit from fat transfer procedure in order to restore the loss of volume in the treated breast [39]. Of note, BR with lipofilling has been shown to be ontologically safe [40]. Advantages of lipofilling for breast reconstruction include the creation of a breast with a natural consistency, minimal scarring, could be use in patients with comorbidities, relatively simple procedure, and low costs [41]. The main limiting factor of this technique is that fat transfer uptake may require multiple fat grafting sessions [42]. This procedure is better offered to patients with small brassiere cup. Some teams report the use of a skin expansion with expander or an expansion device like BRAVA system [43]. Although BR with lipofilling is a relatively new technique, it is gaining in popularity in the United States and worldwide (Figure 11) [44].

Figure 11.

BR with lipofilling. Left: Patient with history of NSM for left BC resulting in contour deformity. Right: patient after Reconstruction with 4 sessions of lipofilling and scar release.

10. Oncoplastic breast reconstruction

In certain BC patients, particularly if they have larger breast size, it is oftentimes possible for them to have the excision of the tumor and have the plastic surgeon perform local breast tissue rearrangement by either lifting the breast or reducing the total size of the breast at the same time that the tumor is being removed. This technique is ideal for a patient with large ptotic breasts who desires breast reduction or lift at the same time of oncologic excision surgery. The advantages are that the tumor is removed with very wide margins and once the tissues are rearranged by way of lifting or reduction, the new breast mound appears even more esthetically pleasing then prior to the patient undergoing surgery. The disadvantages are that the contralateral breast which is not affected from oncologic standpoint is undergoing a surgical procedure as well. Also, many patients are not candidates for this technique especially if their breasts are too small or if the tumor is not in a favorable location (Figure 12) [45, 46].

Figure 12.

46 year old female diagnosed with left invasive breast cancer. Left: preoperative photos. Right: patient after Oncoplastic Surgery with excision of left breast tumor with concurrent bilateral breast reduction.

11. Approach to the opposite breast

Many BC patients who undergo surgical treatment with or without reconstruction oftentimes require treatment to their contralateral breast. The main reason is for symmterization of both breasts and to improve the esthetic outlook. Depending on what treatment is indicated, the contralateral breast may require breast augmentation with implant, breast reduction, or breast lift. When speaking with the BC patients, it is important to make sure they are aware that reconstruction is a process. We must clearly inform the patient not only about the reconstructive options but also symmetrizing procedures that may be needed either at the same time as BR or later on as a separate procedure.

12. Breast implant associated illness

Although rare, it must be mentioned that there are several cases of Breast Implant illness reported in the literature. As of April 1, 2022 The Food and Drug Administration has received a total of 1130 US and global medical device reports of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) [47]. These cases, must be confirmed by pathology/cytology test or Anaplastic Lymphoma Kinase and CD30 biomarkers. More recently, Sept, 2022, the FDA released a new safety communication about Squamous cell carcinoma and various lymphomas in the capsule around breast implants. The current data is limited but evolving. More studies are required to ascertain the magnitude of these findings. Nonetheless, clinical awareness is paramount [48].

13. The impact of post mastectomy radiation therapy on breast reconstruction

Radiation Therapy (RT) is delivered to those patients who are at high risk for developing local recurrence. Indications for radiation therapy include patients undergoing breast conservative surgery as well as patients who undergo mastectomy based on the stage of the tumor and the extent of lymph node metastasis [49]. The need for radiation therapy may not be known until the final pathologic classification of the tumor is completed. Therefore, the reconstructive surgical technique, whether implant based or autologous, should remain the same even in patient who will require post mastectomy radiation therapy. Despite reported data of potential increase in surgical and wound related complications in IBR and to a lesser extent Autologous reconstruction, current literature suggests that there are no absolute contraindications for implant based reconstructions in the setting of post mastectomy radiation therapy [50].

14. Nipple areola reconstruction

Nipple areolar reconstruction (NAR) is the final stage of the breast reconstructive process. The individual who requires NAR is a patient that underwent SSM where the nipple areolar complex is excised as part of the oncologic procedure. In addition, any patient who undergoes NSM, but the nipple areolar complex was compromised due to poor vascularity is a candidate for NAR as well. NAR can be performed as an outpatient procedure under local anesthetic and yields superb results for the patients. Many different techniques are described in the literature for NAR [51]. The authors favorite technique is single stage NAR and tattooing (Figure 13) [52].

Figure 13.

Left: 35 year old female after nipple areolar complex Reconstruction and tattooing in a single stage technique. Right: same patient with side photo showing adequate projection of nipple.

Conflict of interest

The authors declare no conflict of interest.