The purpose of breast reconstruction is to correct breast and chest deformities caused by postoperative breast cancer and to give the patient both physical and psychological treatment. The patient’s condition and local treatment directly affect the choice of the time and method of reconstruction.
I. Timing of breast reconstruction
The timing of breast reconstruction is divided into immediate reconstruction and delayed reconstruction.
Immediate reconstruction means that breast reconstruction and repair are performed at the same time as mastectomy. It has the following advantages: the removal and reconstruction are done at the same time, reducing hospitalization time and cost, so that the patient does not have to go through the pain of losing the breast, does not delay adjuvant radiotherapy or chemotherapy, and does not increase local recurrence. Immediate reconstruction is indicated for stage I, II and III patients.
Delayed reconstruction can be performed at any time after mastectomy.
II. Methods of breast reconstruction
The methods boil down to two main categories: breast prosthesis, i.e. silicone, saline prosthesis and expanders, etc. Autologous tissue
1.Breast reconstruction with prosthesis
Breast implants were used in the early 60s and became popular in the 80s. Nowadays, it is limited to patients with small reconstructed volume, good local soft tissue coverage, young and unwilling to sacrifice other parts of the body. The method is to place a silicone or saline-filled prosthesis under the skin flap or under the pectoralis major muscle after mastectomy. If, after mastectomy, the local tissue does not provide enough cavity to accommodate the desired size of the prosthesis, it can be placed in a skin expander first, and then injected with water periodically after surgery, and when sufficient cavity is formed, the expander is again replaced with a breast prosthesis.
2.Autologous tissue breast reconstruction
Autologous breast reconstruction has long-lasting effect and realistic appearance. It has the following advantages: it can make full use of the patient’s autologous tissue; it can avoid a series of complications brought about by prosthesis; it has good texture and is easy to shape, and can correct subclavian depression and anterior axillary wall deformity; it can not only tolerate postoperative radiation therapy, but also be used for patients who have received radiation therapy and undergone extensive excision due to recurrence; it has good blood tissue to promote the healing of bad wounds and ulcers.
Depending on the origin of the tissue, it can be classified as abdomen, buttock, back, femur, etc. Depending on the mode of metastasis, they can be divided into metastases with tips and free grafts.
2.1 Transverse rectus abdominis muscle flap
With its large tissue volume, good blood flow and simultaneous abdominoplasty effect, it is particularly suitable for middle-aged patients with an already bulging abdomen.
2,1,1 Traditional transverse rectus abdominis muscle flap with rectus abdominis tip
It was first proposed by Hartampf in 1982. Blood flow relies on the superior abdominal wall artery traveling within the rectus abdominis muscle, which is anastomosed by a spiral microartery to reach the inferior abdominal wall artery, which then supplies the flap from a penetrating branch of the inferior abdominal wall artery. Venous return from the flap requires anastomosis through the inferior abdominal wall vein and the spiral micro-artery to reach the superior abdominal wall vein. This approach is often associated with necrosis of the flap and liquefaction of the fat, and the removal of the rectus abdominis muscle increases the risk of abdominal wall weakness and abdominal hernia formation, because of the torsion of the tip and the compression of the tunnel. The transverse rectus abdominis muscle flap with rectus abdominis tip can carry unilateral rectus abdominis muscle as the tip or bilateral rectus abdominis muscle as the tip. Although the latter increases the blood flow of the flap, the excision of the rectus abdominis muscle bilaterally undoubtedly increases the risk of abdominal complications. In order to change the blood flow status of the flap, some authors use flap delay, i.e., ligating the inferior abdominal artery, which is the main blood supply vessel of the flap, 2 to 3 weeks before surgery, and ligating the superficial abdominal artery at the same time. Bilateral vessels are also ligated at the same time. This procedure is suitable for patients with high-risk factors who are not candidates for anastomotic free flap grafting; or for plastic surgeons who do not have microsurgical skills. Another method of improving flap blood flow is to anastomose the inferior abdominal wall artery or superficial abdominal wall artery distal to the flap to the axillary vessels while transferring it with the superior abdominal wall artery with the tip.
2,1,2 Free transverse rectus abdominis muscle flap
With the inferior abdominal wall artery as the tip, proposed by Holmstrom in 1979, a series of anatomic studies have shown that its arterial blood supply comes directly from the penetrating branches of the inferior abdominal wall artery and its venous blood returns directly to the inferior abdominal wall vein. The cut of its vascular tip can carry the whole segment of the rectus abdominis muscle, part of the rectus abdominis muscle or the muscle sleeve. A series of clinical applications have demonstrated the advantage of having fewer complications. The vessels in the recipient area can be either the dorsal scapular artery or the intrathoracic artery, with the former often exposed during axillary clearance. With the increasing refinement of microsurgical techniques, the focus is increasingly on how to reduce donor-area complications while ensuring smooth vascular anastomosis and flap viability.
2,1,3 DIEP of the inferior abdominal wall arteriovenous perforator flap
Proposed and promoted by Koshima, Allen, and Xu Jun in recent years, it is a further refinement of the free transverse rectus abdominis muscle flap. The greatest advantage is that it preserves the integrity of the rectus abdominis muscle and its anterior sheath, avoiding the occurrence of postoperative abdominal wall weakness and abdominal wall hernia, allowing the patient to recover quickly after surgery and having good long-term results. Because of the simultaneous abdominoplasty effect, the inferior abdominal wall arteriovenous perforator flap has become the autologous
tissue graft into the square reconstruction method of choice.
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With the blood vessels of the thoracic dorsum as the tip, a myocutaneous flap or muscle flap can be formed and transferred to the chest with the tip forward, which is simple and easy to perform. It should be commonly used in early stage due to the wound repair after mastectomy for breast cancer. Due to its limited amount of tissue, it often needs to be combined with a breast prosthesis. The dorsal expander muscle flap is also used for debridement and repair of wounds after partial necrosis of the transverse rectus abdominis muscle flap. With the increase in conservative breast therapy, i.e. partial mastectomy plus radiation therapy, and the application of endoscopic techniques, it has made it possible to apply a small axillary incision to simultaneously complete partial mastectomy, axillary clearance, and excision and transfer of the latissimus dorsi muscle flap.
2.3 Gluteus maximus muscle flap
The superior gluteal artery gluteus maximus muscle flap and the inferior gluteal artery gluteus maximus muscle flap can be divided according to their source of blood flow. The former was first proposed by Shaw in 1983. The first case in China was reported by Senkai Li in 1990. The latter was reported by LeQuang and Paletta in 1980 and 1989, respectively, and the gluteus maximus flap is an invisible donor wound for patients with insufficient abdominal tissue or who do not want to leave scars on the abdomen or back. The disadvantages are the need for intraoperative position changes, the short vascular tip, and sometimes the need for venous grafting. When cutting the inferior gluteal artery vasculature, the sciatic nerve should be protected.
2,3,1 Superior gluteal artery perforator flap and inferior gluteal artery perforator flap
Both the superior gluteal artery gluteus maximus flap and the inferior gluteal artery gluteus maximus flap can be perfected as superior gluteal artery perforator flaps and inferior gluteal artery perforator flaps. The vascular perforators are separated from the gluteus maximus muscle fibers to preserve the integrity of the gluteus maximus muscle and reduce complications in the donor area, and to increase the length of the vessel tips for easy vascular anastomosis.
2.4 Broad fascial tensor fasciae muscle flap
Using the lateral vessels of the rotator femoris as tips, first described by Nahai et al. in 1979, it was used for chest wall repair and breast reconstruction in 1990. This procedure requires strict indications and is certainly a two-pronged approach for patients with flat abdomen and buttocks and bulging thighs on both sides.
2.5 Rubens flap
An iliolumbar flap with a deep iliac vessel as the tip. Proposed by Taylor in 1979. It is suitable for patients with a flat abdomen and buttocks and a full iliolumbar region.
3.Correction of contralateral breast
If the contralateral breast is too large, too small or sagging, and the reconstructed breast cannot be symmetrical with it, a breast reduction, augmentation or breast fixation is needed for the contralateral breast.
Nipple areola reconstruction
Nipple areola reconstruction is an indispensable part of breast reconstruction. Nipple reconstruction can be completed at the same time as breast reconstruction, or when the shape of both breasts is finally stabilized. There are many methods of nipple reconstruction, including free tissue grafting or local flap method. Free tissue grafts can be applied to the contralateral nipple, earlobe or labia minora. However, the local flap method is now commonly used. Areola reconstruction can be performed by free skin grafting or tattoo technique.