Related narrative: TRAM Breast Reconstruction
Breast Reconstruction has become an established part of the comprehensive care of breast disease. Ideally, a reconstructed breast is made symmetrical with the other, in no more than two operative procedures. The first step is to reconstruct the breast in one of a number of ways, at the same time addressing the opposite breast if necessary with mastopexy, reduction, or augmentation in order to achieve symmetry. The second procedure involves reconstructing a nipple-areola complex. The reconstruction can take place at the time of the mastectomy or postsurgically. Both methods can achieve good results, but immediate reconstruction provides an open operative field without scarring, eliminates the need for a second anesthesia, and reduces the psychological effects of waking up without a breast. Immediate reconstruction does not delay the institution of adjuvant chemotherapy whuch can usually begin within 6 weeks of surgery. Large preoperative doses of chemotherapy, however, can interfere with wound healing. If postoperative radiation is prescribed, the surgeon will generally delay reconstruction to avoid unsatisfactory results. Radiation therapy after reconstruction, especially with implants, can cause fibrosis and contraction of the reconstructed breast.
Two types of postmastectomy breast reconstruction are performed. One uses an implant, either with or without a tissue expander. The other uses autologous tissue dissected from one area of the body and moved to the breast area. An implant can also be used in conjunction with autologous tissue reconstruction. If the tissue is moved leaving its own blood supply intact, it is referred to as pedicled. A free flap is disconnected from its blood supply and attached to regional vessels near the chest using microsurgical techniques. Several donor sites are currently used to harvest tissue for reconstruction of the breast. These types of procedures are complex and involve significant risk of scarring and potential morbidity, though their increasing popularity has improved results.
The extent of pathology determines the possibility of reconstruction (see breast cancer staging). Patients with stage I of II disease are generally candidates. Patients with more advanced disease may later be candidates for reconstruction after treatment and an appropriate disease-free interval. For minimal lesions, skin-sparing mastectomies followed by reconstruction are becoming more common, and they offer the best-looking result. The surgeon removes the total breast through a periaerolar approach, and except for the nipple-areola complex, the whole skin envelope is preserved. This is a technically challenging procedure, but the aesthetic outcome is excellent. The rate of local cancer recurrence is no greater than that for a standard mastectomy. In reconstruction, filling the envelope with autologous tissue yields the best result.
When there is limited skin for immediate implant placement, a tissue expander may be used as a first stage. The expander is placed beneath the pectoralis major muscle, and over a few weeks or months is expanded with saline until it can be replaced with a permanent saline or silicone implant. The choice of implant, tissue reconstruction or a combination depends on individual circumstances.
Transverse Rectus Abdominis Musculocutaneous Flap
The TRAM flap is the most common method of autologous tissue augmentation. Contraindications to this procedure include having a previous TRAM flap, previous abdominoplasty, previous abdominal liposuction, small vessel disease, obesity, chronic lung disease, or severe cardiovascular disease. Patients considering autologous tissue surgery using the TRAM flap should be informed of the procedure's complexity, which involves lengthy hospitalization (approximately 5 days) and a recovery of 6-12 weeks.
The TRAM flap procedure involves dissecting a section of the abdomen that includes skin, subcutaneous fat, and a segment of the rectus abdominis muscle. The surgeon moves the dissected section, along with the intact blood supply from the superior epigastric artery and vein, to the breast through a tunnel under the mid-abdominal skin. The flap may be unilateral or bilateral. The unilateral TRAM may be done with the contralateral or ipsilateral muscle. A synthetic mesh is used to support the abdominal wall where the rectus has been removed.
Serious surgical complications of the TRAM procedure include flap necrosis, abdominal hernia, umbilical necrosis, abdominal skin necrosis, fat necrosis, and decreased abdominal muscle strength. Partial flap loss occurs in 2-6% of cases and total flap loss is rare. Draining the site can usually prevent postoperative seromas.
Latissimus Dorsi Musculocutaneous Flap
Many patients who undergo reconstruction with a latissimus dorsi myocutaneous flap do not meet the criteria to receive a TRAM flap for reconstruction. The latissimus dorsi flap is also considered an option for women who need minimal tissue or have a significant layer of subcutaneous tissue at the donor site. Also, women who have thin skin at the mastectomy site and will probably not benefit from tissue expanders may opt for this procedure. The latissimus dorsi flap can also be used in conjunction with an implant in a one-step procedure if more breast mound mass is wanted. Factors that determine the location extent of the donor site include the amount of donor tissue required and the desired location of the postsurgical scar. The fleur-de-lis flap, which is a type of latissimus flap, resembles an inverted "T" and results in maximal flap volume. The latissimus dorsi flap and the thoracodorsal vessels that provide blood to the donor site are passed through a subcutaneous tunnel formed high in the axilla.
Free Tissue Transfer
Several donor sites for free-flap procedures exist, including the TRAM free flap, superior gluteal free flap, inferior gluteal free flap, tensor fascia latae flap, groin flap, contralateral latissimus dorsi flap, and contralateral breast wedge. A surgical concern with patients who have been irradiated and want autologous tissue replacement with free flaps is the state of the recipient vessels. The advance of microsurgical techniques has improved the outcome of this type of surgery, resulting in its increased use. Only a few of the above-listed donor sites are commonly used:
TRAM Free Flap
Free TRAM flaps utilize the larger inferior epigastric vessels as the pedicle and the vessels are reconnected using microvascular technique. No tunnel between abdomen and breast is needed. Reoperation to revise a compromised blood supply is necessary in about 5% of cases. Complications include those inherent in standard TRAM flaps in addition to the increased risk to the blood supply.
Gluteal and tensor fasciae latae flaps offer options for patients in whom the standard workhorse flaps are not possible.
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