Breast Reconstruction Following Mastectomy

Transcription

1 C C a n c e r J C l i n ; 4 5 : reast Reconstruction Following Mastectomy John ostwick III, MD Introduction reast cancer poses a dual threat to women attacking their lives as well as their femininity. s the incidence of breast cancer continues to rise among women of all ages, the need for early detection becomes more pressing. key to reducing the mortality from this disease is educating women that cure without permanent breast loss is possible if their cancer is diagnosed early. Vital to this process are monthly breast self-examinations, breast imaging with mammography and other tests to detect small tumors before they can be felt, and periodic breast examinations by a health care professional. 1 The merican Cancer Society recommends a baseline mammogram for all women before the age of 40 and then one every one to two years until the age of 50. t age 50 and after, women should have yearly mammograms. ccredited breast imaging centers with registered technologists and board-certified mammographers are now available throughout the country to monitor women for signs of breast cancer before it is detectable by physical examination. When a suspicious area is identified on a mammogram or a Dr. ostwick is Professor of Surgery and Chairman of the Division of Plastic, Reconstructive and Maxillo-facial Surgery at the Emory University School of Medicine in tlanta, Georgia The author thanks Karen erger and Jean ried, P, MPH, for their assistance in the preparation of this manuscript. lump is detected on physical examination, needle aspiration or surgical biopsy may be necessary to sample the cells or tissues to determine if breast cancer is present. Today women diagnosed with breast cancer may choose among several viable options for primary treatment of their cancer without permanent physical disfigurement. 2 reast-conserving surgery (lumpectomy) and axillary lymph node dissection followed by radiation therapy is a treatment widely available for many women with stage I and stage II breast cancer who have relatively small tumors with a low probability of local recurrence. 3 With this approach a woman s breast is preserved, but surgery is necessary to remove the tumor, the surrounding margins, and the axillary lymph nodes. The other common therapy for breast cancer in the United States is modified radical mastectomy (complete removal of the breast plus axillary lymph node dissection). This treatment can be combined with immediate or delayed breast reconstruction for breast restoration. Modified radical mastectomy is recommended when breast conservation and radiation therapy will not yield an acceptable aesthetic result; when the tumor is large, multifocal, or extensive; or if the chance of recurrence is likely if mastectomy is not performed. In the past most breast reconstructions were performed as delayed procedures, but this is no longer the case. e- Vol. 45 No. 5 September/october

2 r e a s t r e c o n s t r u c t i o n cause there are now many breast cancer teams skilled in performing immediate breast reconstruction, this is becoming a frequent choice for breast reconstruction. Reconstructive techniques are also available to treat deformities that result after lumpectomy and radiation therapy or when local recurrence requires a mastectomy. The ultimate decision for treatment of a woman s breast cancer should be a mutual one made by the patient and her surgeon after considering the medical as well as the psychological aspects of this disease. 4-6 reast Cancer Management Team Comprehensive treatment of the woman with breast cancer requires the talents of a number of specialists. For this reason optimal treatment is best delivered by a team approach, whereby a number of experts work together to care most effectively for the patient. This team includes the surgeon, the breast-imaging specialist, the pathologist, the medical oncologist, the radiation oncologist, and the plastic surgeon. They are supported by nurse clinicians, medical social workers, and volunteers of the merican Cancer Society. Reach to Recovery For many years the Reach to Recovery volunteer has played a vital role in ministering to the needs of women with breast cancer. In this merican Cancer Society program, trained volunteers who have had breast cancer visit new breast cancer patients by appointment and with physician authorization. These skilled volunteers are a source of information and encouragement, providing appropriate literature for the patient and her loved ones, supplying temporary breast forms when needed, and answering questions. The Reach to Recovery volunteer usually makes one visit, with a possible second visit as follow-up. She does not give medical advice; rather she relates her own positive experience, offers support, and serves as a role model of a recovered breast cancer patient who is living proof of how someone has successfully coped with breast cancer and resumed her everyday activities. 7 To meet the varying needs of women with breast cancer and in response to advances in management of this disease, the Reach to Recovery Program has expanded its scope. Many chapters now have different volunteers available who have undergone breast-conserving surgery, breast reconstruction, radiation therapy, and chemotherapy and can discuss their experiences and provide helpful information to women who are considering one of these approaches for treatment or rehabilitation. Other support organizations are also available locally and nationally to help women and their families learn more about breast cancer and cope with the problems and adjustments that this disease necessitates. Some breast cancer patients may decide to join a support group of other women who have had breast cancer. Information about these programs is available from the merican Cancer Society. Role of reast Reconstruction in Treating the reast Cancer Patient efore breast reconstruction techniques became available, breast cancer treatment was limited to eradication of the cancer. The emotional and psychological devastation that some women felt after breast loss was largely neglected. For these women the mastectomy deformity served as a constant reminder of their life-threatening disease. Many experienced feelings of depression, disfigurement, and impaired body image. The external prosthesis used to replace the missing breast was often not an adequate solution. It was usually not incorporated into the woman s body image as a restored breast, and for physically active 290 Ca cancer Journal for Clinicians

3 C C a n c e r J C l i n ; 4 5 : Fig. 1. () This 44-year-old woman had a recent right breast biopsy indicating infiltrating lobular carcinoma. () She chose bilateral total mastectomies with immediate breast reconstruction using tissue expanders (shown here two years postoperatively). women, it could be cumbersome, uncomfortable, and easily displaced during sports and other activities. In the last two decades, breast reconstruction has progressed from a rarely requested procedure to one that is an integral part of a woman s breast cancer management when local treatment for her disease is considered. The development of new techniques and their application by well-trained reconstructive surgeons have resulted in more natural and aesthetically acceptable reconstructions. Experience over the past twenty years has demonstrated that breast reconstruction is a safe and reliable operation; it does not hide local recurrences and does not accelerate the rate or risk of breast cancer spread. In addition, breast reconstruction yields positive psychological benefits for many women, offering them a sense of normality, a return to wholeness, and an opportunity to put the cancer experience behind them. Women who elect to have immediate reconstruction say that it helps them to avoid the sense of deformity after mastectomy. 8 reast reconstruction also provides a welcome solution when a local recurrence or problem (such as asymmetry or fibrosis) develops after breast-conserving surgery. breast deformity or mastectomy for the woman who initially had lumpectomy and radiation therapy may be especially devastating because of the high priority she placed on body image when she originally selected breast-conserving treatment rather than a mastectomy. reast reconstruction can help to alleviate this woman s sense of deformity. Reconstructive surgery in this setting, however, is medically challenging and can be more difficult because now the surgeon is working with irradiated tissues that are relatively inelastic. In this case, a flap procedure using the patient s own tissue is often the best reconstructive method. Selection and Timing of reast Reconstruction woman s motivation and desire for a restored breast are the most important indicators for breast reconstruction. This operation can be performed immediately at the time of the mastectomy or after a delay as a second operation. Immediate Vol. 45 No. 5 September/october

4 r e a s t r e c o n s t r u c t i o n Fig. 2. () 48-year-old woman seven months after a modified radical mastectomy for breast cancer. She desired no alterations of her normal left breast. () Two years after right breast reconstruction using an implant. breast reconstruction has become an appealing option for women undergoing mastectomy, and they are choosing it with greater frequency because it combines a proven treatment for breast cancer with immediate breast restoration. 9,10 This approach ameliorates the woman s experience of breast loss and the psychological and physical problems that this causes. Immediate breast reconstruction is appropriate for most women with stage I and stage II breast cancer. It usually does not interfere with or delay adjuvant chemotherapy. However, when a complication develops, it may be necessary to wait to begin adjuvant chemotherapy until the wound is healed. If the woman has locally advanced (stage III) breast cancer, it is advisable to begin adjuvant therapy as soon as possible; in this case reconstruction should be postponed until therapy is completed and a woman s blood count has returned to normal. Careful preoperative planning between the surgical oncologist and the reconstructive surgeon is required when the mastectomy and breast reconstruction are combined. The results of this teamwork, however, can be beneficial. Immediate breast reconstruction often permits shorter incisions with less skin removal. y preserving certain breast landmarks such as the inframammary fold, the result may also be better balanced than when the breast reconstruction is done later during a second operation. Only one hospitalization, one anesthesia, and one rehabilitation are necessary with this approach. Immediate breast reconstruction does not imply, however, that the entire reconstruction is completed in one procedure; additional operations are usually needed to rebuild the nipple-areola and to achieve the best aesthetic results (Fig. 1). For some women delayed breast reconstruction is the best or the only option. These women may have had their mastectomies years earlier before they knew that breast reconstruction was possible. Others may choose a delayed procedure because they do not have access to a reconstructive surgeon or because they prefer to approach their treatment one step at a time, first completing the cancer therapy and then after an appropriate interval having their breast reconstructed. This delay also gives a woman more time to weigh all of her options, to decide if she 292 Ca cancer Journal for Clinicians

5 C C a n c e r J C l i n ; 4 5 : Fig. 3. () This 35-year-old woman had a previous left modified radical mastectomy for breast cancer with resultant tight chest wall tissue. She chose tissue expansion breast reconstruction. () Two years after tissue expansion followed by implant exchange, nipple-areola reconstruction and right augmentation for breast symmetry. Note the natural ptosis achieved in the left breast. wishes to proceed with reconstructive surgery, to select a reconstructive surgeon, and to decide on the appropriate reconstructive technique. s with immediate breast reconstruction, the nipple and areola are usually reconstructed during a separate procedure after the reconstructed breasts are stable and symmetrical. reast Implants and reast Surgery The silicone gel-filled breast implant was first developed in 1963 for women with small breasts who desired breast augmentation. The same technology was later applied to breast reconstruction to restore the breast shape and contour in women who had mastectomies. Over the past 30 years, more than one million women in the United States have had breast surgery with implants. The reported satisfaction level with these procedures has been high. For women with mastectomies, these devices have represented the simplest, most economical, least time-consuming approach to breast restoration. Despite the long experience with breast implants, they have become the source of widespread controversy, publicity, and misunderstanding during the past few years. Much of this turmoil was precipitated by hearings of the Food and Drug dministration on silicone gelfilled breast implants that were held in 1991 to evaluate these devices. (n FD review of saline-filled implants is scheduled in 1998 after over five years of prospective studies.) lthough the media attention that these public hearings received seemed to imply that the ongoing FD investigation is evidence of wrongdoing or hidden dangers, that is not the case. Retrospective studies do not show an association of breast implants and connective tissue diseases or breast cancer. fter public hearings and careful review of these devices, the FD has stated that silicone gel-filled implants do not pose a health hazard. This is not to say that they are totally problem free or that they do not require further study. Saline-filled implants are now most frequently used for breast reconstuctions. There are risks and benefits associated with all devices; breast implants are no exception. 8 The most common problem associated with breast implants is capsular contracture. capsule is a firm, fibrous scar Vol. 45 No. 5 September/october

6 r e a s t r e c o n s t r u c t i o n C Fig. 4. () This patient had a previous right modified radical mastectomy and a protuberant lower abdomen. She requested reconstruction, an abdominoplasty, and a left breast reduction. () Two and a half years after breast reconstruction with a bipedicle transverse rectus abdominus myocutaneous flap and a left small reduction mammoplasty. (C) Lateral view, preoperative. (D) Lateral view, postoperative. D that forms around a breast implant as it does around all devices that are placed in the body. This is the body s natural response to any foreign body. When the scar tissue thickens and causes breast firmness, the condition is called capsular contracture. The severity of this problem varies. When minor, no treatment is necessary; when severe, a minor operation (usually done on an outpatient basis) may be required to release the scar tissue or remove it. lthough capsular contracture may be uncomfortable and impair the aesthetic result, it is not dangerous to a woman s health. reast implants may also interfere with mammograms, particularly when capsular contracture has occurred. woman who has implants should always inform the mammographer so that special 294 Ca cancer Journal for Clinicians

7 C C a n c e r J C l i n ; 4 5 : displacement views can be taken to more effectively visualize her breast tissue. reast implants are not considered permanent devices. They have the potential to rupture, develop leaks, or become displaced. If a saline-filled breast implant develops a leak, the saline solution is harmlessly absorbed by the body. If a leak or problem develops, the breast implant can be exchanged for another, usually during an outpatient procedure with the patient under local anesthesia. How long a woman can expect the implant to remain intact has not been determined. That is one of the questions that current clinical studies are attempting to answer. 11 Concerns about serious health dangers associated with breast implants have not been substantiated. Large, retrospective clinical studies have not demonstrated that breast implants cause or increase the incidence of breast cancer or that they impair follow-up after breast cancer. Questions raised about a possible link between breast implants and connective tissue disorders such as scleroderma, lupus, rheumatoid arthritis, and some conditions characterized by weakness, joint stiffness, and fatigue, remain unsupported. No causal relationship has been scientifically documented. Studies do not show that an association exists. There are some C Fig. 5. () This 38-year-old woman had a right modified radical mastectomy deformity. Due to a family history of breast cancer indicating a higher risk for contralateral cancer, she chose elective left total mastectomy and bilateral breast reconstruction. () Two months after left immediate and right delayed breast reconstruction using bilateral transverse rectus abdominus myocutaneous flaps. skin-sparing technique was used for her left total mastectomy. (C) One year after breast reconstruction followed by bilateral nipple-areola reconstruction. Vol. 45 No. 5 September/october

8 r e a s t r e c o n s t r u c t i o n C D Fig. 6. () TRM flap designed on the lower abdomen. () bdominal tissue transferred to breast area while still attached to the rectus abdominus muscle (single pedicle). (C) bdominal tissue fashioned into a breast and lower abdominal tissue closed as a transverse scar. (D) Nipple-areola reconstructed several months later. recent studies that indicate that antibodies may form in response to silicone; however, this information is not correlated with any disease process, and antibodies represent a natural body reaction to any foreign substance. The use of saline-filled breast implants and expanders remains unrestricted; gel implants will probably not be available in the future. Techniques of reast Reconstruction Today with the development of new, improved techniques to satisfy women s requests for breast reconstruction, women can choose from a number of procedures that provide the aesthetic improvement and psychological benefit that they desire. woman s breast can now be rebuilt 296 Ca cancer Journal for Clinicians

9 C C a n c e r J C l i n ; 4 5 : using implants or expanders and the tissue remaining after the mastectomy or with flaps of muscle or muscle and skin obtained from the abdomen, back, or buttock regions. The type of reconstructive technique chosen depends on a woman s physical condition, her personal preferences, and the surgeon s expertise. 12,13 REST RECONSTRUCTION WITH IMPLNTS ND TISSUE EXPNDERS Many patients prefer a simple method of breast reconstruction that does not involve a long convalescence. For these women, an implant or expander reconstruction is a good choice. Issues of money, time, and lifestyle are their primary concern, and they do not object to the use of a foreign material, particularly if it will simplify the rehabilitation process and avoid additional scarring. For these individuals a breast implant, tissue expander, or expander implant can be positioned through the mastectomy incision, beneath the chest wall muscles, and behind the plane of the modified radical mastectomy. 14 Implant surgery is appropriate for reconstructing the breasts of women whose opposite breast is small to moderate size and has minimal ptosis. The breast implant is selected to match the opposite breast in volume, shape, and contour (Fig. 2). Currently available implants usually contain saline solution. With modern breast reconstruction techniques, most patients have a tissue expander rather than a breast implant Pectoralis major muscle Implant Latissimus dorsi muscle Subcutaneous port of expander implant Latissimus skin island Fig. 7. () Latissimus dorsi flap, showing orientation of the skin island to be transferred to the breast. () Position of the latissimus dorsi flap after transfer. It is sutured superiorly to the pectoralis major muscle and inferiorly to create the inframammary crease; the implant is completely covered with muscle tissue. Vol. 45 No. 5 September/october

10 r e a s t r e c o n s t r u c t i o n C Fig. 8. () This 42-year-old woman had a left modified radical mastectomy deformity and a ptotic right breast. She requested breast reconstruction without abdominal scarring. () Several months after breast reconstruction with a latissimus dorsi flap plus an implant, nipple-areola reconstruction, and right mastopexy for breast symmetry. (C) Preoperative view of latissimus dorsi donor site. (D) Postoperative view of latissimus dorsi donor site. D placed at the time of the initial procedure. Tissue expansion permits breast reconstruction without using distant flaps. It simplifies breast reconstruction and minimizes scarring (Fig. 3). larger and more natural-appearing ptotic breast can often be achieved with tissue expansion than by placing a breast implant under the available tissues. Tissue expanders are adjustable implants that can be inflated with normal saline solution to stretch the tissues at the mastectomy site; they can be temporary or permanent. Currently, the most popular devices for breast reconstruction are the permanent expander implant, the postoperatively adjustable implant, and the temporary expander. The permanent expander implant has a small remote valve placed under the skin, usually in the underarm area, for the injection of saline to permit adjustments in breast size in the postoperative period. This fill valve can be removed to convert the ex- 298 Ca cancer Journal for Clinicians

11 C C a n c e r J C l i n ; 4 5 : Fig. 9. () This 24-year-old woman had a previous left modified radical mastectomy for ductal carcinoma. She had a thin scarred abdomen and she rejected scarring on her back. She chose inferior gluteal free-flap reconstruction. () Eighteen months after inferior gluteal free-flap reconstruction followed by nipple-areola reconstruction. pander to a permanent breast implant once the ideal breast size has been determined. The postoperatively adjustable implant has a small separate fill valve that does not require removal. This implant is an alternative to the temporary expander and is being used with increasing frequency for implant reconstructions because it affords the best possible control over the final breast size. The temporary expander has an integral valve that is located with a magnet so that the saline can then be injected through the skin and into the device to adjust it in the postoperative period; once tissue expansion is complete, this expander is removed and replaced with a permanent implant. These implants are available in several contoured or anatomic shapes to give the best contour. Tissue expansion usually requires two operations. First, the tissue expander is positioned through the mastectomy scar beneath the musculofascial layer of the chest wall, and sterile saline solution is then introduced through the valve. Postoperatively, after about one to two weeks, the tissues are expanded by serial injections of saline solution. The tissue expander is overfilled and then reduced to the appropriate size to allow for additional stretch and to enhance the softness of the final breast reconstruction. t a second operation the tissue expander may be exchanged for a permanent breast implant of the proper size, or if a permanent expander implant is used, the fill valve can be removed to convert the tissue expander to a permanent breast implant. 15 Valve removal is not required for the postoperatively adjustable implant. s discussed earlier, capsular contracture is the most common problem associated with implants or expanders. If it develops, the breast can become firm and spherical, producing breast asymmetry; the implant may also become displaced. Placement of the implant or expander beneath the musculofascial layer rather than under the subcutaneous tissues has reduced the incidence of capsular contracture. These devices are available with smooth or textured surfaces. Initial expe- Vol. 45 No. 5 September/october

12 r e a s t r e c o n s t r u c t i o n Inferior gluteal artery Skin Island Sciatic nerves Fig. 11. Design for an inferior gluteal free flap, showing the skin island and the position of the inferior gluteal artery. a few months later or another type of breast reconstruction is selected. The use of a latissimus dorsi muscle flap at the time of immediate breast reconstruction can reduce the possibility of breast implant extrusion. Fig. 10. () Preoperative view of inferior gluteal free flap donor site (see patient in Figure 9). () Right inferior gluteal donor site several months postoperatively; suction-assisted lipectomy was performed on the left at the time of nipple-areola reconstruction. rience with the textured-surface devices indicates that they seem to reduce the incidence of capsular contracture at least in the first few years after implantation. Other possible complications include infection or hematoma. fter an immediate breast reconstruction with tissue expansion, if there is some difficulty with healing of the skin or if an infection causes the incision to open, the breast implant can become exposed and require removal. In this situation, the area is allowed to heal and the implant is replaced FLP RECONSTRUCTION dvances in breast reconstruction during the past decade now offer women the option of having breast reconstruction with their own tissues (autologous) without the need for breast implants or expanders. Musculocutaneous flaps permit the transposition of substantial amounts of skin, underlying fat, and muscle from the back, 16 lower abdomen, 17 or buttocks 18 to the chest area for breast reconstruction. These are the three most common sources of the patient s own tissue for breast reconstruction. ecause the donor site is usually an area of tissue excess, it can often be contoured to produce a more aesthetic appearance. Flap reconstructions are particularly helpful in situations in which skin is needed to rebuild a woman s missing breast. With immediate breast reconstruction, the use of a flap can often permit the creation of a breast that is symmetrical with the opposite breast without modifying it. These flaps are also necessary for a natural-appearing breast reconstruction if the 300 Ca cancer Journal for Clinicians

13 C C a n c e r J C l i n ; 4 5 : woman has a radical mastectomy deformity, if the remaining skin is irradiated or tight, or if the other breast is full and sags. The transfer of these musculocutaneous flaps is possible because the blood supply to the overlying skin and subcutaneous tissue comes from the underlying muscle via musculocutaneous perforators. When tissue from the abdominal wall and back is used, it is left attached to the blood supply of the muscle beneath it (a musculocutaneous flap). When buttock tissue is used, microsurgical techniques are necessary to restore the blood supply to the flap by reattaching the vessels supplying this tissue to those in the breast region. Microsurgery can also be used to move a flap of abdominal tissue (TRM flap) for breast reconstruction; however, most surgeons feel that this tissue can be moved more reliably and expeditiously when it is left attached to its muscle and blood supply (a pedicled flap). ecause flap procedures can cause more blood loss than breast reconstruction with local tissues and implants or expanders, transfusion may be necessary. Patients are asked to donate one or more units of autologous blood prior to the operation so that it is available if needed. Transverse Rectus bdominis Musculocutaneous (TRM) Flap For some breast cancer patients who have excess lower abdominal tissue, it is possible to move an ellipse of lower abdominal fat and skin as a musculocutaneous (TRM) flap to the breast area and to fashion it into the shape of a new breast (Fig. 4). When the amount of chest skin removed with the mastectomy is minimal, the outer covering of the skin of the TRM flap can be taken off, and the flap positioned to give the proper breast contour without a breast implant. The TRM flap is now the most frequently used flap operation and provides some of the most attractive and realistic breast reconstructions. With this operation, a woman s large opposite breast can often be matched without modification. It can be used to rebuild a woman s breasts after total mastectomy, modified radical mastectomy, or even radical mastectomy. 19,20 When the TRM flap is used for immediate reconstruction, the surgeon is often able to limit the amount of skin removal and to shorten the length of the mastectomy scar (Fig. 5). The TRM flap is nourished by the blood supply entering the lower abdominal fat through perforators from the underlying rectus abdominis muscle. This flap is based on the superior epigastric artery, a terminal branch of the internal mammary artery. These vessels course through the chest and the upper rectus abdominis muscle, join the vessels of the deep inferior epigastric artery, and then penetrate the fascia around the umbilicus to supply the fat and skin of the TRM flap. The TRM flap operation is complex and requires the skill of a reconstructive surgeon experienced in the technique as well as a properly selected patient who understands the magnitude of the operation. The operation takes from two to six hours in the operating room compared to the one to two hours required for implant or expander reconstruction. The woman is usually in the hospital for four to seven days. Recovery takes about six weeks. fter this operation the rebuilt breast usually has an elliptical scar pattern, and the donor scar extends across the lower abdomen between the pubic area and umbilicus (Fig. 6). This musculocutaneous flap depends on good microcirculation. When the blood supply is compromised secondary to cigarette smoking, obesity, hypertension, or diabetes mellitus, there may be insufficient blood flow to the flap. For these patients, a procedure called a vascular delay can be done in which some lower abdominal vessels are divided to make the flap more reliable. careful and secure abdominal closure, sometimes Vol. 45 No. 5 September/october

14 r e a s t r e c o n s t r u c t i o n reinforced with nonabsorbable mesh, is needed to tighten the abdominal wall and avoid a postoperative hernia. Under certain conditions it may be advisable to use a microsurgical technique to move the TRM flap to the breast area for breast reconstruction. In this situation the tissue is totally separated from the abdominal wall (as opposed to the pedicle TRM, which is left attached to the blood supply of the muscle beneath it) and transposed to the chest wall where the vessels supplying the tissue are reattached to the vessels in the axilla. This is called a TRM free flap and requires a reconstructive surgeon with additional expertise in microsurgery. 21 It is more technically demanding than the pedicle TRM and requires more operative time. primary indication for a free flap is when an upper abdominal wall scar indicates prior surgical division of the normal blood supply to the TRM flap. ecause the TRM flap is a major operation, complications occur with greater frequency. Delayed healing or even loss of some or rarely all of the flap is possible. Other possible complications include bleeding (hematoma), infection, and hernia. Venous clots in the legs are a rare but serious complication. Latissimus Dorsi Musculocutaneous Flap latissimus dorsi flap technique is selected when additional tissue is needed to rebuild mastectomy defects and the TRM flap is not available or other reasons prevent its use. While some patients can have their breasts rebuilt with the back tissue without a breast implant or expander, many women do not have sufficient excess back tissue and require an implant or permanent expander implant to provide additional volume for the reconstructed breast. In this operation skin and muscle, or sometimes only muscle, from a woman s back are transferred around to the breast area to replace the skin and muscle removed during mastectomy. This is a safe, reliable flap with a good blood supply (Fig. 7). The latissimus dorsi flap is also useful to supplement the skin at the mastectomy site and to provide additional muscle cover for an implant or expander when the reconstructed breast needs to be fuller and more ptotic or when the other breast is to be matched at the time of an immediate breast reconstruction. latissimus dorsi flap provides implant cover so that the reconstructed breast has a more natural appearance. 22 The possibility of implant exposure is also reduced after immediate breast reconstruction. lthough the latissimus dorsi musculocutaneous flap is very reliable, like the TRM flap, it is also a more complex operation than simple implant or expander placement. It usually takes from two to four hours to perform, and hospitalization is required. Inset of the flap results in additional scars on the breast and a donor scar where the flap was designed on the back (Fig. 8). These scars can be reduced in length when this flap is used for immediate breast reconstruction. Complications are similar to those described for the TRM flap. The possibility of partial or total flap failure exists for any flap procedure. bout two percent of patients have partial tissue loss when this flap is used. reast reconstruction with the latissimus dorsi musculocutaneous flap also usually requires the use of a breast implant or expander, introducing the possibility of subsequent capsular contracture. Hematoma, infection, and fluid collection (seroma) are other possible problems that may develop. Gluteus Maximus Musculocutaneous Flap with Microsurgical Transfer When a flap procedure is needed and the previously described flap techniques are not suitable, a breast can be reconstructed with fat and skin from the lower but- 302 Ca cancer Journal for Clinicians

15 C C a n c e r J C l i n ; 4 5 : tocks region (gluteus maximus free flap) (Fig. 9). natural, full breast can be reconstructed with the patient s own tissues with a donor scar that is hidden in the buttock area (Fig. 10). This method can also provide reconstruction without the need for a breast implant. Patients selected for this procedure must be healthy and able to undergo at least four to eight hours of surgery. During this operation the tissue needed for the breast reconstruction along with a small segment of the gluteus maximus muscle are elevated on a vascular pedicle. The buttocks tissue is transferred to the breast area and the vessels reattached with a microvascular technique (Fig. 11). 23 reast reconstruction using this microvascular technique is the most technically demanding of all breast reconstruction techniques. It is also prone to more serious complications, because it takes longer to perform and usually requires an extended hospital stay of four to six days. Inset of the flap in the breast requires additional breast scars, and the donor scar is in the buttocks area. Liposuction may also be needed to contour the opposite buttock for symmetry. The survival of the new breast depends on successful anastomosis of the vessels and maintenance of patency in the postoperative period. compromised blood flow can result in tissue death unless the flow is reinstated. Fluid accumulation, hematoma, and infection are also possible as are the other complications described with the TRM flap. NIPPLE-REOL RECONSTRUCTION Nipple-areola reconstruction contributes to a natural and realistic breast appearance and is usually performed during a separate procedure about three months after the breast reconstruction, once satisfactory breast symmetry has been obtained. The nipple is usually reconstructed with tissues available at the site of the new nipple. New reconstructive techniques use the skin and subcutaneous tissue of the breast mound to create a nipple with satisfactory projection. The nipple can also be reconstructed with a graft taken from an opposite large nipple. With refinement of techniques using local tissue, however, this method is being used much less frequently. The areola is reconstructed so that it is symmetrical and similar in diameter and color to the areola of the opposite breast. 24 The areola reconstruction can be done with excess skin taken from the lateral chest area. The most common method now relies on the use of a tattoo to create the semblance of an areola without the need for a skin graft. fter the nipple-areola reconstruction has healed, intradermal tattoo is used to achieve maximal color symmetry with the natural nipple-areola. Summary Modern breast reconstruction techniques provide the woman faced with breast cancer with a reliable source of rehabilitation and an alternative to breast loss subsequent to cancer treatment. s a member of the breast management team, the reconstructive surgeon provides valuable input on the appropriate timing and techniques for surgery. With the surgical oncologist and the plastic surgeon working together, the mastectomy and breast reconstruction can often be combined in one operation with less skin removal, shorter scars, and reduced inconvenience for the patient. Techniques of tissue expansion permit breast reconstruction without additional scars or significant hospitalization. With the development of autogenous tissue breast reconstruction techniques, women are also able to have natural, long-lasting breast reconstruction without the need for a breast implant. C Vol. 45 No. 5 September/october

16 r e a s t r e c o n s t r u c t i o n References 1. Holleb I (ed): The merican Cancer Society s Cancer ook: Prevention, Detection, Diagnosis, Treatment, Rehabilitation and Cure. Garden City, NY, Doubleday & Co, alch CM, Singletary SE, land KI: Clinical decision-making in early breast cancer. nn Surg 1993;217: Harris JR, Hellman S, Henderson IC, Kinne D: reast Diseases, 2nd ed. Philadelphia, J Lippincott Co, Harris JR, Lippman ME, Veronesi U, Willet W: reast cancer [first of three parts]. N Engl J Med 1992;327: Harris JR, Lippman ME, Veronesi U, Willet W: reast cancer [second of three parts]. N Engl J Med 1992;327: Harris JR, Lippman ME, Veronesi U, Willet W: reast cancer [third of three parts]. N Engl J Med 1992;327: Lasser T, Clark WK: Reach to Recovery. New York, Simon & Schuster, erger K, ostwick J III: Woman s Decision: reast Care, Treatment and Reconstruction, 2nd ed. St. Louis, Quality Medical Publishing, Noone R, Murphy J, Spear SL, Little JW: 6- year experience with immediate reconstruction after mastectomy for cancer. Plast Reconstr Surg 1985;76: Schain WS, Wellisch DK, Pasnau RO, Landsverk J: The sooner the better: study of psychological factors in women undergoing immediate versus delayed breast reconstruction. m J Psychiatry 1985;142: Council on Scientific ffairs. merican Medical ssociation: Silicone gel breast implants. JM 1993;270: ostwick J III: Plastic and Reconstructive reast Surgery. St. Louis, Quality Medical Publishing, merican Cancer Society: reast Reconstruction after Mastectomy. Pub No tlanta, merican Cancer Society, Little JW, Golembe EV, Fisher J: The living bra in immediate and delayed reconstruction of the breast following mastectomy for malignant and nonmalignant disease. Plast Reconstr Surg 1981; 68: ecker H: reast reconstruction using an inflatable breast implant with detachable reservoir. Plast Reconstr Surg 1984;73: Schneider WJ, Hill HL Jr, rown RG: Latissimus dorsi myocutaneous flap for breast reconstruction. r J Plast Surg 1977;30: Hartrampf CR, Scheflan M, lack, PW: reast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg 1982;68: Paletta CE, ostwick J III, Nahai F: The inferior gluteal free flap in breast reconstruction. Plast Reconstr Surg 1989; 84: Ishii CH Jr, ostwick J III, Raine TJ, et al: Double-pedicle transverse rectus abdominis myocutaneous flap for unilateral breast and chestwall reconstruction. Plast Reconstr Surg 1985; 76: Hartrampf CH: reast reconstruction with a transverse abdominal island flap: retrospective evaluation. Perspect Plast Surg 1987;1: Grotting FF, Urist MM, Maddox W, Vasconez LO: Conventional TRM flap versus free microsurgical TRM flap for immediate breast reconstruction. Plast Reconstr Surg 1989;83: iggs TM, Cronin ED: Technical aspects of the latissimus dorsi myocutaneous flap in breast reconstruction. nn Plast Surg 1981;6: Nahai F: reast reconstruction with a free gluteus maximus musculocutaneous flap. Perspect Plast Surg 1993;6: Little JW, Spear S: Nipple-areola reconstruction. Perspect Plast Surg 1988;2: Ca cancer Journal for Clinicians