Outline for Breast Reconstruction:

Two Major Forms of Breast Reconstruction: (1) Implant Based Breast Reconstruction (2) Autologous Based Breast Reconstruction 

Timing:

Both can be performed in either an immediate fashion (or at the time of mastectomy) or in a delayed fashion (or after mastectomy and therapy for breast cancer is complete) 

Implant Based Breast Reconstruction: 

Stages: 

• Direct to Implant 
• Patient Selection: 
• Small to moderate sized breasts 
• Minimal to no ptosis or skin excess
• Desire to have a postoperative volume similar or smaller to their current breast volume 
• Relative Contraindications: 
• Any mastectomy technique that places stress on the skin envelope including tumors close to the skin  
• Staged (placement of a tissue expander and exchange to a permanent implant 
• Tissue Expanders 
• Although not commonly used – Carbon dioxide expanders are on the market. You are unable to deflate these expanders which can complicate radiation if needed. Outcomes show no difference in complications and a faster expansion process overall.

Placement of the Implant: 

• Prepectoral implant placement:  
• Advantages: 
• No animation deformity 
• Decreased pain with implant placement 
• Disadvantages: 
• Increased rate of rippling 
• Higher reported rates of capsular contracture although use of ADM decreases this risk 
• Speaking of ADM – typically implants placed in the prepectoral plane was covered with ADM. This decreases the risk of capsular contracture but increases the risk of postoperative seroma formation. 
• Subpectoral: 
• Advantages: 
• Provides greater padding to reduce rippling especially in thin patients
• Disadvantages: 
• Animation deformity and pain 

Radiation: 

• Radiation significantly increases complications with alloplastic reconstruction including increased risk of mastectomy flap necrosis, capsular contracture and infection. 
• What device should we radiate: 
• Radiation to the tissue expander has increased rates of reconstructive failure as compared with radiation to implant, however, has a better aesthetic result (less capsular contracture). Additionally, placement of a tissue expander allows for deflation of the TE if needed to facilitate radiation 
• Overall,. tissue expander based reconstruction remains a good choice in patients whose radiation status is undetermined (may receive radiation) as it preserves the patient’s skin envelope and keeps open options for definitive final reconstruction.

Antibiotics? 

• Infection rate around 8% for breast reconstruction. Most common organisms are staphylococcus for gram positives and pseudomonas for gram negatives. 
• Timing of perioperative antibiotics is currently under review:
• ASPS currently recommend that antibiotics should be discontinued < 24 hours after surgery unless drains are present, in which case prophylaxis duration is left to surgeon preference. 
• Philips et. al . published a non-inferiority RTC among patients undergoing immediate implant-based reconstruction with the use of acellular dermal matrix. They compared the recommended 24 hours of abx to abx continued until drain removal and found no difference between the groups. Suggesting that stopping abx 24 hours following surgery was sufficient. 

Autologous Based Breast Reconstruction:

Commonly Used Flaps for Autologous Reconstruction:

• DIEP (Deep Inferior Epigastric Artery Perforator) Flap: 
• The DIEP is a variation of the TRAM and msTRAM – the difference is that with a DIEP the perforators are dissected out from the rectus muscle leaving behind the entire muscle and muscle fascia 
• Arterial anatomy: The DIEP is an artery that comes off of the external iliac 
• Perfusion zones: 
• Medial row perforators are zones I and II (ipsilateral and contralateral). Lateral rows are zones III (ipsilateral) and IV (contralateral) 
• Medial row perforator flaps are perfused in this order I-II-III-IV
• Lateral Row perforator flaps are perfused in this order I-III-II-IV
• Relative contraindications to a DIEP flap include prior abdominal surgery, prior liposuction and large pannus. 
• Prior C section is not a relative contraindication to DIEP flap surgery. In fact, pfannenstiel incisions typically divide the superficial epigastric circulation and gives this flap more robust venous circulation (decrease in fat necrosis of flap) due to the delay phenomenon.
• Typical preoperative workup:
• CTA are now commonly used to delineate the perforator anatomy prior to surgery to reduce operative time 
• Intraoperative Monitoring: 
• Florescent angiography – relies on indocyanine green 
• Postoperative monitoring tools
• Vioptix – tissue perfusion 
• Cook dopplers 
• Clinical Exam 
• Patient Reported Outcomes: 
• Studies support improved patient satisfaction with autologous reconstruction in the setting of unilateral reconstruction; also provides better symmetry when compared to implant
• Variations to the DIEP Flap:
• Variations to the Sensation: may coapt intercostal nerves from breast to segmental intercostal nerve through flap (rectus) typically T10.

As a side-note the SIEA (superficial inferior epigastric artery) perforator flap is described for breast reconstruction however, these flaps have a higher failure rates than DIEP flaps , less muscle bulges, similar fat necrosis rates. Bases blood supply on SIEA which is topically less robust than DIEA system. This is performed by surgical delay by ligating the DIEA system may facilitate overall viability
PAP (profunda artery perforator) flaps

• Arterial Anatomy:  PAP is based off of perforators for the profunda artery that typically travel through the adductor magnus muscle 
• The flap can be oriented either vertically down the medial thigh or horizontally along the posterior medial thigh. The amount of skin that can be safely taken is generally based on the pinch test preoperatively but is reported most commonly to be around 7cm 

Alternative Flaps for Breast Reconstruction: 

• Thigh Flaps: 
• TUG (transverse upper gracillis) flap: Ellipse of anteromedial thigh with superior border within the gluteal fold. Based on perforators from the descending branch of medial circumflex artery
• Gluteal Flaps:
• IGAP (inferior gluteal artery perforator) flap: Design includes ellipse of skin of the inferior buttock with inferior border within the gluteal fold
• SGAP (superficial gluteal artery perforator) flap: Design includes ellipse of skin in the middle buttock from PSIS (posterior superior iliac spine) to the apex of the greater trochanter.

Complications of free flap breast reconstruction

• Flap related complications: 
• Flap Loss: 
• Arterial: 
• Cause: arterial thrombus
• Presentation: these patients will have a cool, pale flap with a rapid decrease in vioptix signaling. 
• Treatment: urgent operative exploration for salvage 
• Venous congestion:
• Cause:  venous thrombosis, inadequate perforator selection, superficial venous dominance. 
• Presentation: present as blue color, brisk capillary refill, cooler skin temperature, rapid bleeding of dark blood on pinprick
• Treatment: emergent exploration. Salvage rates are higher if explored within 6 hours. In the operating room, if venous anastomosis is open, consider second anastomosis with SIEV (superficial dominant system)
• VTE: 
• patients following long surgeries such as free flap reconstruction are at a higher risk of lower extremity VTE due to venous stasis in the lower extremities following sugery.
• Based on the Caprini risk assessment model  – ASPS VTE task force recommends those undergoing elective plastic surgery who have score of 7 or greater to have VTE risk reduction strategies: limiting OR time, weight reduction, discontinuation of hormone therapy, early postoperative mobilization, consider extended use of LMWH
• Highest risk factors include age >75, DVTPE hx, Positive factor V leiden, HIT, elevated anticardiolipin or serum homocysteine or prothrombin or lupus anticoagulant, congenital or acquired thrombophilia, family history of thrombosis.
• Delayed Wound Healing: this is associated with BMI > 35
• For DIEP flaps: abdominal complications including hernia, bulge or weakness 

Revision Surgeries: 

• Contralateral Symmetry procedures: 
• frequently necessary to achieve symmetry after mastectomy and reconstruction and include mastopexy, reduction mammaplasty, augmentation/mastopexy. These can be performed safely at the same time as unilateral autologous tissue reconstruction
• Fat grafting: 
• Fat grafting can be used in conjunction with implant placement and autologous breast reconstruction to improve contour deformities.  This has no higher risk for breast cancer but can increase incidence of benign lesions (cysts and calcifications)
• Nipple Reconstruction:
• Blood supply based off of subdermal plexus and considered random pattern blood supply
• Techniques include skate flap, star flap, C-V flap.
• The most common complication includes loss of projection.
• Patients who seek nipple reconstruction report increased rates of satisfaction, quality of life

BIA-ALCL (breast implant associated anaplastic large cell lymphoma)

• Presentation: 
• The majority of cases of BIA-ALCL present with late-onset seroma (66-80%), whereas the second most common presentation is an isolated mass within the capsule around the implant.
• Typically associated with a textured implant placement 
• Evaluation: 
• Workup with ultrasound followed by FNA
• Lab tests: CD30 positive and ALK negative
• Treatment: Surgical treatment for BIA-ALCL can vary with the stage of presentation, but BIA-ALCL confined to the periprosthetic fluid can be effectively treated with capsulectomy and implant removal.

Miscellaneous

• Biggest factors for receiving breast reconstruction from previous studies include distance from reconstructive surgeons and insurance status.
• Women’s health and cancer rights act: requires insurance plans to cover the cost of breast reconstruction after mastectomy
• Includes all stages of reconstruction as well as contralateral procedures to provide symmetry
• Does not apply to women undergoing breast conservation therapy (lumpectomy with radiation)