In a life time breast cancer affect 1 in 10 women. The last decade has borne fruit in the management of these unfortunate patients. Breast conservative surgery (removal of only the lump with a rim of normal breast tissue) provided radiotherapy is delivered to the breast following the surgery has shown equivalent tumour control and survival to a mastectomy. The critical issue though is the relative size of the breast to the tumour mass and the latters position. In general the lump size must be small relative to the breast size. Poor judgement in offering breast conservative surgery can therefore result in breast deformities robbing the patient of her confidence.
An alternative approach to the same situation and also based on the type of breast cancer is a mastectomy. The advantage of this approach for early breast cancer is that there is no need for post surgical radiotherapy. The mastectomy equates to complete loss of the breast. Every woman with early breast cancer has a choice to avoid breast deformities or mastectomy defect. An immediate reconstruction can be offered together with the ablative surgery to immediately restore the body image and form. In most cases it is preferred that in the planning stage of the cancer surgery the need for postoperative radiotherapy is not likely. For patients that do not qualify for immediate reconstruction a delayed reconstruction is a very good option.The following options based on the type of cancer surgery are available.
Therapeutic mammoplasty: The technique of breast reduction is used to rearrange the breast tissue following removal of the breast lump. Any deformities associated with the lumpectomy is avoided at the expense of the making the breast slightly smaller. The opposite breast will also require to be operated on to match both breasts.
Parenchymal breast flap: If the situation allows then the mammoplasty can be avoided. Without making additional external incisions breast tissue within the breast can be rearranged to fill the space left behind by the removal of the lump. Another advantage of this is that it also avoids an operation to the opposite normal breast.
Parenchymal breast flap: Local chest or abdominal flap: in the event that the breast is small then the tissue for replacing the space left behind by removing the lump a flap adjacent to the breast can be taken from the abdomen or the chest. Usually scars left behind by this form of reconstruction are minor and unobtrusive.
ii. Skin sparing vs nipple preserving mastectomy
In a skin sparing mastectomy the skin of the breast is not sacrificed and the underlying breast tissue is removed. The skin envelope is then filled by a breast substitute. To achieve this a common choice is to have flap taken from another part of the body. If the patient does not desire use of another donor site then the tissue expander or breast implant is a good option In some cases the nature and the position of the tumour allows for the preservation of the nipple aerolar complex with the breast skin.
Tissue expansion or breast implants: The prosthesis is placed under the pectoralis muscle. This achieves complete cover of the implant with reliable tissue with a good blood supply. A tissue expander is used when a nipple aerolar complex cannot be preserved. This needs to be replaced with breast prosthesis a later stage when adequate skin is created.
Latissimus Dorsi musculocutaneous flap:This block oif tissue is taken from the back. The nipple can be reconstructed from the skin and it is brought to the front. The muscle is used to completely cover the breast implant which needs to be used for restoration of the volume of the breast. If a fairly small breast is being reconstructed then the flap on its own maybe adequate for volume restoration.
Free tissue transfer: The commonly used flap is the DIEP flap which is taken from the lower part of the abdomen. The defect is closed in the same fashion as performing a tummy tuck. The main advantage of this flap is that the reconstruction uses only the patient’s own tissue. Most women that have borne children have suitable volume of tissue to make up the breast. In the women that this is not suitable other sites are available in the body to achieve the same. This technique relies on the reconnection of blood vessels. Therefore there is a small risk of failure in the reconstruction. In the event of failure a salvage alternative technique has to be performed at the same or at a later stage.
The delayed breast reconstruction is only performed once adjuvant treatment in terms of radiotherapy and chemotherapy is complete. Even if the breast cancer is locally advanced at the time of the surgery it does not contraindicate a delayed reconstruction of the breast. If there has been treatment with radiotherapy to the chest then the reconstruction has to be delayed to 1 to 2 years following completion. This allows for softening of the tissue and also becomes a relative measure of being disease free for the reconstruction of the breast.
The delayed breast reconstruction is only performed once adjuvant treatment in terms of radiotherapy and chemotherapy is complete. Even if the breast cancer is locally advanced at the time of the surgery it does not contraindicate a delayed reconstruction of the breast. If there has been treatment with radiotherapy to the chest then the reconstruction has to be delayed to 1 to 2 years following completion. This allows for softening of the tissue and also becomes a relative measure of being disease free for the reconstruction of the breast
i. Fat injection
This has enjoyed popularity in the recent past. Fat is extracted from a site of the body by liposuction. The fat is processed and then injected into the tissue under the skin of the breast to make up the breast mound. To reach the final breast form the procedure may need to be repeated up to 3 times. The number of stages can be decreased if the chest skin is expanded with the BRAVA technique. The advantage of fat injection is that mesenchymal stem cells are also injected into to the tissue. Past radiotherapy is not a contraindication for fat injection. In fact sometimes it can be the treatment of choice post radiotherapy situation to improve the quality of the tissue in preparation for reconstruction by tissue expansion or by other methods. This technique can also be used to fill secondary deformities related to lumpectomy. Overall this method of reconstruction does not have any significant donor morbidity and recovery is quick.
ii. Tissue expansion and prosthesis
This is the ideal form of reconstruction if a donor site is to be avoided. Ideal requirement to achieve this is good skin quality that has adequate of thickness of subcutaneous fat. Skin that has been radiated is generally not suitable and the other techniques should be used. Tissue expansion is a multi-staged procedure and the entire process can take up to 6 months. The initialprocedure involves the placement of a tissue expander under the skin and muscle. Once the incision line is healed the inflation with normal saline is started until the desired volume is reached. A period of consolidation is allowed for softening of the tissue before the expander is removed and exchanged for a breast prosthesis.Symmetrization of the opposite breast is performed to match the reconstructed side. Alternatively this can be postponed to a later stage when the nipple aerolar complex reconstruction is done.
iii. Breast implant and autologous latissimusDorsi flap
This is predictable method of reconstructing the breast. Postmastectomy skin deficiency is made up by the transfer of the skin and muscle of the back. The donor area is closed directly. The volume and the shape of the breast are made up by the use of breast prosthesis. The breast prosthesis can come in a round or anatomical shape.
iv. Autologous only flap reconstruction eg. TRAM flap
This method of reconstruction comes with a significant advantage of using only tissue from the body. Therefore complications and problems associated with the use of a silicone prosthesis is not present. A more natural looking mature breast can also be achieved. The flap is taken from the lower portion of the tummy which after the harvest is closed as a tummy tuck. The flap is transferred to the chest using the rectus abdominus muscle to be carried with a blood supply. The sacrifice of the muscle is well tolerated in most people.
v. Free DIEP flap
This method also achieves reconstruction of the breast by harvesting tissue of the lower part of the tummy. The donor is also closed as a tummy tuck. The major advantage is that the rectus abdominus muscle is sparedwith no resultant weakness in the abdominal wall. The technique relies on the use of microsurgery. The blood supply is established by harvesting the lower tissue of the abdomen with intact blood vessels that then need to be reconnected to vessels of the chest. This is a much more reliable technique in a patient with a BMI greater than 30. There is also good versatility in manipulating the tissue to establish a good breast shape. The major disadvantage is the risk of total failure of the reconstruction. This risk is generally in the region of about 2%.