Breast Reconstruction

https://doi.org/10.1016/j.suc.2018.03.011Get rights and content

Section snippets

Key points

  • Many options exist for postmastectomy and postlumpectomy breast reconstruction.

  • Surgeons must present all options to safely offer reconstruction, based on patient preferences and adjuvant treatment effects.

  • Postmastectomy reconstruction outcomes have been enhanced, in terms of aesthetics and outcomes, by nipple-sparing mastectomy, autologous fat grafting, acellular dermal matrices, and prepectoral breast reconstruction.

  • Reconstructive outcomes are heavily influenced by postmastectomy radiation

Postmastectomy breast reconstruction

After mastectomy, implant-based breast reconstruction is the most commonly performed option. Either through the traditional 2-stage approach with tissue expansion, or through the single-stage (direct to implant) approach, these options produce highly aesthetic breasts in a multitude of sizes (Fig. 1).6, 7

The immediate placement of a tissue expander or permanent implant at the time of mastectomy is preferable, owing to the ability to use the shape of the breast skin envelope and achieve an

Nipple-sparing mastectomy

In recent years, the frequency of nipple-sparing mastectomy being offered has increased significantly, owing to expanding indications and inclusion criteria.9 Equivalent locoregional recurrence rates to skin sparing mastectomy, in patients with stages 1 through 3 tumors, and no preoperative nipple skin involvement, has resulted in many more patients being offered this option. This factor has enhanced the appearance of breast reconstructive outcomes, because retention of the native nipple/areola

Postmastectomy radiation

Breast reconstruction in the setting of postmastectomy radiation therapy (PMRT) represents a particular challenge, owing to higher reported rates of incisional dehiscence, infection, and capsular contracture. Reported rates of overall complications in this setting range from 15% to 40%. This challenge occurs frequently with rates of PMRT in some centers reported at rates of 30% to 40%.14

When planning prosthetic reconstruction with PMRT, the surgeon must first decide whether radiation will be

Prepectoral breast reconstruction

Traditionally, prosthetic breast reconstruction after mastectomy has involved placing a tissue expander or permanent implant not only under the preserved breast skin, but also underneath the pectoralis major muscle. This was also assisted in coverage by incorporating the serrauts anterior muscle or fascia, or more recently, ADM for additional coverage.28 The purpose of such submuscular placement of prosthetic devices is the belief that this results in lower rates of capsular contracture,

Autologous fat grafting

Of all advances in breast reconstruction in the last 10 years, perhaps that with the greatest impact has been the advent of autologous fat grafting. With this technique, autologous fat can be harvested from a patient’s body using liposuction techniques. The fat is then washed, to remove blood and oil, and immediately reinjected into the breast for volume restoration, soft tissue augmentation, and masking of contour deformities.

In the setting of prosthetic breast reconstruction, this technique

Oncoplastic (postlumpectomy) breast reconstruction

Although postmastectomy breast reconstruction remains the most commonly performed oncologic reconstruction technique, the rise of oncoplastic breast reconstruction, performed alongside partial mastectomy (breast conservation) procedures, has been rapid. This finding is due to the potential severity of postlumpectomy breast defects, and the desire to avoid them. As such, 2 oncoplastic techniques are now commonly employed used the time of partial mastectomy: local tissue rearrangement and

First page preview

First page preview
Click to open first page preview

References (42)

  • C.R. Albornoz et al.

    A paradigm shift in U.S. breast reconstruction: increasing implant rates

    Plast Reconstr Surg

    (2013)
  • American Society of Plastic Surgeons. 2016 procedural statistics. Arlington Heights (IL). Available at:...
  • A.K. Alderman et al.

    The national utilization of immediate and early delayed breast reconstruction and the effect of sociodemographic factors

    Plast Reconstr Surg

    (2003)
  • E.G. Wilkins et al.

    Breast reconstruction practices in North America: current trends and future priorities

    Semin Plast Surg

    (2004)
  • Y. Eltahir et al.

    Quality-of-life outcomes between mastectomy alone and breast reconstruction: comparison of patient-reported BREAST-Q and other health-related quality-of-life measures

    Plast Reconstr Surg

    (2013)
  • H. Sbitany et al.

    Preferences in choosing between breast reconstruction options: a survey of female plastic surgeons

    Plast Reconstr Surg

    (2009)
  • A.S. Colwell et al.

    Retrospective review of 331 consecutive immediate single-stage implant reconstructions with acellular dermal matrix: indications, complications, trends, and costs

    Plast Reconstr Surg

    (2011)
  • S.A. Macadam et al.

    Evidence-based medicine: autologous breast reconstruction

    Plast Reconstr Surg

    (2017)
  • A.W. Peled et al.

    Expanding the indications for total skin-sparing mastectomy: is it safe for patients with locally advanced disease?

    Ann Surg Oncol

    (2016)
  • C.R. Bailey et al.

    Quality-of-life outcomes improve with nipple-sparing mastectomy and breast reconstruction

    Plast Reconstr Surg

    (2017)
  • F. Wang et al.

    The impact of breast mass on outcomes of total skin-sparing mastectomy and immediate tissue expander-based breast reconstruction

    Plast Reconstr Surg

    (2015)
  • M. Alperovich et al.

    Nipple-sparing mastectomy in patients with a history of reduction mammaplasty or mastopexy: how safe is it?

    Plast Reconstr Surg

    (2013)
  • F. Wang et al.

    Total skin-sparing mastectomy and immediate breast reconstruction: an evolution of technique and assessment of outcomes

    Ann Surg Oncol

    (2014)
  • H. Sbitany et al.

    Tissue expander reconstruction after total skin-sparing mastectomy: defining the effects of coverage technique on nipple/areola preservation

    Ann Plast Surg

    (2016)
  • P.G. Cordeiro et al.

    What is the optimum timing of postmastectomy radiotherapy in two-stage prosthetic reconstruction: radiation to the tissue expander or permanent implant?

    Plast Reconstr Surg

    (2015)
  • M.B. Nava et al.

    Outcome of different timings of radiotherapy in implant-based breast reconstructions

    Plast Reconstr Surg

    (2011)
  • H. Sbitany et al.

    Immediate implant-based breast reconstruction following total skin-sparing mastectomy: defining the risk of preoperative and postoperative radiation therapy for surgical outcomes

    Plast Reconstr Surg

    (2014)
  • A.W. Peled et al.

    Impact of total skin-sparing mastectomy incision type on reconstructive complications following radiation therapy

    Plast Reconstr Surg

    (2014)
  • A.W. Peled et al.

    Increasing the time to expander-implant exchange after postmastectomy radiation therapy reduces expander-implant failure

    Plast Reconstr Surg

    (2012)
  • R.M. Garza et al.

    Studies in fat grafting: part III. Fat grafting irradiated tissue–improved skin quality and decreased fat graft retention

    Plast Reconstr Surg

    (2014)
  • A.K. Seth et al.

    Utility of acellular dermis-assisted breast reconstruction in the setting of radiation: a comparative analysis

    Plast Reconstr Surg

    (2012)
  • Cited by (25)

    • Breast reconstruction with silicone prosthesis and acellular dermal matrix of porcine origin: Retrospective study of 84 cases

      2022, Annales de Chirurgie Plastique Esthetique
      Citation Excerpt :

      An increasing number of patients present sequelae, particularly aesthetic ones, following oncological treatment (medical and surgical treatments). The demand for breast reconstruction (BR) is growing leading to the development of numerous techniques which can be adapted to each woman [2]. There are techniques for reconstruction by free flap or not, giving excellent aesthetic results but are complex and not always accepted by patients.

    View all citing articles on Scopus

    Disclosure Statement: Dr H. Sbitany is a consultant for Allergan, Inc. He received no compensation or support for this article.

    View full text