Breast reconstruction

From Wikipedia, the free encyclopedia - View original article

 
Jump to: navigation, search
Result of breast reconstruction after mastectomy. Nipple missing, and cicatrix (scar) is prominent.

Breast reconstruction is the rebuilding of a breast, usually in women. It involves using autologous tissue or prosthetic material to construct a natural-looking breast. Often this includes the reformation of a natural-looking areola and nipple. This procedure involves the use of implants or relocated flaps of the patient's own tissue.

Overview[edit]

The primary part of the procedure can often be carried out immediately following the mastectomy. As with many other surgeries, patients with significant medical comorbidities (high blood pressure, obesity, diabetes) and smokers are higher-risk candidates. Surgeons may choose to perform delayed reconstruction to decrease this risk. There is little evidence available from randomised studies to favour immediate or delayed reconstruction.[1] The infection rate may be higher with primary reconstruction (done at the same time as mastectomy), but there are psychologic and financial benefits to having a single primary reconstruction. Patients expected to receive radiation therapy as part of their adjuvant treatment are also commonly considered for delayed autologous reconstruction due to significantly higher complication rates with tissue expander-implant techniques in those patients.

Breast reconstruction is a large undertaking that usually takes multiple operations. Sometimes these follow-up surgeries are spread out over weeks or months. If an implant is used, the individual runs the same risks and complications as those who use them for breast augmentation but has higher rates of capsular contracture (tightening or hardening of the scar tissue around the implant) and revisional surgeries.

Outcomes based research on quality of life improvements and psychosocial benefits associated with breast reconstruction [2][3] served as the stimulus in the United States for the 1998 Women's Health and Cancer Rights Act[1], which mandated health care payer coverage for breast and nipple reconstruction, contralateral procedures to achieve symmetry, and treatment for the sequelae of mastectomy. This was followed in 2001 by additional legislation imposing penalties on noncompliant insurers. Similar provisions for coverage exist in most countries worldwide through national health care programs.

Techniques[edit]

There are many methods for breast reconstruction. The two most common are:

Breast Reconstruction using a Tissue Expander.
Transverse Rectus Abdominis Myocutaneous flap (TRAM).
Post-operative state after Transverse Rectus Abdominis Myocutaneous flap(TRAM).

Other considerations[edit]

To restore the appearance of the breast with surgical reconstruction, there are a few options regarding the nipple and areola.

  • Nipple-Areolar Composite Graft (Sharing) - if the contralateral breast has not been reconstructed and the nipple and areolar are sufficiently large, tissue may be harvested and used to recreate the nipple-areolar complex on the reconstructed side.
  • Local Tissue Flaps - a nipple may be created by raising a small flap in the target area and producing a raised mound of skin. To create an areola, a circular incision may be made around the new nipple and sutured back again. The nipple and areolar region may then be tattooed to produce a realistic colour match with the contralateral breast.
  • Local Tissue Flaps With Use of AlloDerm - as above, a nipple may be created by raising a small flap in the target area and producing a raised mound of skin. AlloDerm (cadaveric dermis) can then be inserted into the core of the new nipple acting like a "strut" which may help maintain the projection of the nipple for a longer period of time. The nipple and areolar region may then be tattooed later.[7] There are however some important issues in relation to NAC Tattooing that should be considered prior to opting for tattooing, such as the choice of pigments and equipment used for the procedure.[8]

One of the challenges in breast reconstruction is to match the reconstructed breast to the mature breast on the other side (often fairly 'ptotic' - droopy.) This often requires a lift (mastopexy), reduction, or augmentation of the other breast.

Follow-up and recovery[edit]

Recovery from implant-based reconstruction is generally faster than with flap-based reconstructions, but both take at least three to six weeks of recovery and both require follow-up surgeries in order to construct a new areola and nipple. All recipients of these operations should refrain from strenuous sports, overhead lifting, and sexual activity during the recovery period. TRAM flap patients can show abdominal-muscle weakness on electromyogram (EMG) studies, but clinically most patients who have undergone unilateral breast reconstruction (reconstruction of one breast only) return to normal activities after recovery.

Patients who have undergone bilateral breast reconstruction with TRAM flaps (i.e. reconstruction of both breasts) require sacrifice of both rectus muscles and tend to have permanent abdominal strength loss. For this reason, many plastic surgeons now frown upon bilateral breast reconstruction with TRAM flaps. This also explains the significant patient interest in perforator flap techniques such as the DIEP flap which preserves abdominal muscle function long-term. These patients tend to return to full activity after several weeks without permanent limitations.

There is little information about upper body exercise post-mastectomy. Issues such as simple mastectomy, mastectomy with reconstruction, and mastectomy with lymph node excision and reconstruction all factor into limitations to amount and extent of upper body exercise. Generally, cardiac exercise (treadmill, walking, etc.) are approved for rehabilitation post-surgery and for weight control.[citation needed]

Women who have undergone breast reconstruction must still be followed for local or regional recurrence of their cancer with manual exams of the breast/chest wall and axilla.

The most effective relief from breast reconstruction is hilotherapy, a therapy that provides relief from hematoma, pain, and swelling post-surgery without the dangers of frostbite and skin necrosis.[citation needed]

See also[edit]

Additional images[edit]

References[edit]

  1. ^ D'Souza, N; Darmanin, G; Fedorowicz, Z (Jul 6, 2011). "Immediate versus delayed reconstruction following surgery for breast cancer.". The Cochrane database of systematic reviews (7): CD008674. PMID 21735435. 
  2. ^ Harcourt, DM, Rumsey, NJ, Ambler, NR, et al. The psychological effect of mastectomy with or without breast reconstruction: a prospective, multicenter study. Plast Reconstr Surg 2003; 111:1060. PMID 12621175
  3. ^ Brandberg, Y, Malm, M, Blomqvist, L. A prospective and randomized study, "SVEA," comparing effects of three methods for delayed breast reconstruction on quality of life, patient-defined problem areas of life, and cosmetic result. Plast Reconstr Surg 2000; 105:66. PMID 10626972
  4. ^ Breuing KH, Warren SM. Immediate bilateral breast reconstruction with implants and inferolateral AlloDerm slings. Ann Plast Surg. 2005 Sep;55(3):232-9. PMID 16106158
  5. ^ Salzberg CA. Nonexpansive immediate breast reconstruction using human acellular tissue matrix graft (AlloDerm). Ann Plast Surg. 2006 Jul;57(1):1-5. PMID 16799299
  6. ^ Ferry Melchels et al. 2011 Biofabrication 3 034114 doi:10.1088/1758-5082/3/3/034114
  7. ^ Garramone, D.O., Charles E; Lam, Ben (May 2007). "Use of AlloDerm in primary nipple reconstruction to improve long-term nipple projection.". Plastic and reconstructive surgery 119 (6): 1663–8. doi:10.1097/01.prs.0000258831.38615.80. PMID 17440338. 
  8. ^ A. Darby. 3D Nipple Tattooing a New Service? (inc revisions). CosmeticTattoo.org Educational Articles 24/10/2013

External links[edit]