Breast reconstruction has come a long way. Though an attempt at breast reconstruction was described in 1895, the notion that breast reconstruction should be given serious consideration after cancer surgery is a phenomenon of the last 50 years. The single most important event in the history of breast reconstruction was the passage of the 1998 Federal Breast Reconstruction Law, cited as the “Women’s Health and Cancer Rights Act of 1998”. This legislation requires that insurance companies providing coverage in connection with a group health plan must cover reconstruction of the breast on which the mastectomy has been performed, as well as surgery of the other breast to produce a symmetrical appearance.
For plastic surgeons, breast reconstruction is an integral part of their training and for many, a primary focus of their careers. There are a wide range of techniques used, and current techniques represent a significant evolution in the field. Early attempts at fat grafting were not predictable and were abandoned as other techniques became available. Beginning in the 1960s, breast implants became the focus of attention for reconstruction. As various techniques for transferring tissue were developed, use of a patient’s own tissue has been established as an important method of breast reconstruction. The most recent advances in breast reconstruction include:
- Methods to reduce scarring on the reconstructed breast by way of skin-sparing mastectomy
- Methods to reduce the potential complications from the donor site by way of muscle-sparing flaps and perforator flaps
- The changing mindset and elevated standards for aesthetic outcomes, which has led to an increased number of procedures performed on the contralateral breast for improved symmetry
Skin-Sparing Mastectomy Though the technique of skin-sparing mastectomy is harder for the breast surgeon to perform, the potential for improved cosmetics makes it worthwhile in certain circumstances. In some cases, breast size, tumor size, tumor location, presence of other scars, or other patient factors precludes the use of this technique. The importance of the skin-sparing technique is that it results in a more natural appearance, with less scarring and fewer visible patches of skin from other areas of the body. The skin-sparing mastectomy seeks to remove only the nipple complex along with the breast tissue. If additional access to the axilla is required, an extension of the circular incision can be made, or a separate incision can be made in the armpit. Early involvement of the reconstructive surgeon is an important factor in planning this technique. Potential downsides include the increased technical difficulty for the breast surgeon and the increased chance of skin loss on the mastectomy flaps.
Muscle Sparing Flaps Though implants remain a good option for breast reconstruction, many women will opt for use of their own tissue. Use of the lower abdominal skin and fat (TRAM flap) is a common technique and is associated with excellent, natural-appearing results. One of the downsides to this technique has always been the sacrifice of the rectus abdominis muscle. This muscle runs up and down the abdominal wall and is associated with abdominal wall strength as well as other functions, such as deep breathing and coughing. Despite the importance of the rectus muscle, sacrifice of one or even both muscles is well tolerated by most patients undergoing this procedure. Nevertheless, the development of techniques to harvest the excess skin and fat of the lower abdomen, while preserving muscle strength and function is one of the most exciting new developments in this field.
When breast reconstruction is done using TRAM flap, complete removal of the tissue from the body and re-attachment of the blood vessels to a new blood supply in the chest allows for these muscle-sparing techniques to be implemented. These techniques are technically far more challenging than the standard TRAM flap, in which the muscle is left attached as a leash, providing the blood supply to the new breast. The advantage is the ability to harvest only a small amount of muscle, or no muscle at all, as is done in a variation called the DIEP (Deep Inferior Epigastric Perforator) flap. This operation seeks to preserve abdominal wall strength and function. The disadvantage to these techniques is the increased time required for the operation, the technical difficulty involved, and the chance for complete failure of the flap if the blood vessels clot off. The level of difficulty and time required for these procedures have limited the number of plastic surgeons who perform them. At centers in which a high volume of these procedures are performed, the results are excellent.
Implants The use of implants in breast reconstruction remains a popular technique. The avoidance of scars on other parts of the body, the quicker recovery period, and the technical ease with which they can be used make them appealing to many women and surgeons. Though silicone implants were suspected of causing a number of illnesses, no studies have shown any conclusive data that links them to serious systemic disease processes. Nevertheless, silicone implants are limited in their use in the United States (though not in other countries) by the FDA. Silicone implants have a more natural feel and are softer than saline implants. Because of this, many patients are willing to participate in studies to determine the safety of these implants. Only plastic surgeons who are enrolled as investigators in the silicone implant studies can offer silicone implants to their patients for breast reconstruction. Saline implants do not have the same risk factors as silicone and their use is unrestricted. As longer term data on silicone implants accrues, it appears very likely that in the near future, silicone implants will be given clearance for unrestricted use. Modifications in implant designs will undoubtedly follow.
There are a wide variety of implant shapes, sizes, and profiles available. The myriad types of implants to choose from ensure that the vast majority of body types can be addressed. The high profile implants are the newest addition to the available implants and they have improved results tremendously. These implants are particularly useful in women with narrow chest walls. They are designed to accommodate a wider range of fill volumes. This is an important factor for plastic surgeons when replacing a breast with an implant and hoping to achieve balanced, proportional result.
Procedures for Symmetry Current techniques for breast reconstruction have the potential to create outstanding results. As expectations for outcomes have risen, so has the consideration for achieving symmetry. The federal breast reconstruction legislation of 1998 mandates insurance coverage for procedures on the opposite breast in order to achieve symmetry. As a result of these two things, more women are being offered additional procedures directed at the opposite breast. Though breast reduction and lifting procedures have been commonly performed on extremely large or hanging breasts, more consideration is now given to fine tuning the results with use of implants. The use of an implant can provide a shape that better matches the roundness of a breast reconstructed with an implant only. Additionally, use of implants alone to augment the opposite side when trying to achieve symmetry is commonly done and considered an essential component of the breast reconstruction on the opposite side.
ConclusionsThe evolution of breast reconstruction reflects a growing concern for women’s health, both physical and emotional. Procedures to reconstruct the breast in both women and men who have undergone treatment for cancer is no longer considered unnecessary , as it was in the first half of the 20 th century. Paralleling the development of refined techniques for transferring tissue, techniques for breast reconstruction have advanced dramatically in the last several years. Some of these procedures are among the most challenging that plastic surgeons perform. Though there will always be people who do not opt for reconstruction or who are not candidates, current techniques ensure that the vast majority of people who desire reconstruction after mastectomy will be able to be reconstructed with the goal of a balanced and aesthetic result.