Breast cancer is a common malignancy in women and poses a fatal threat to women’s health. Although breast-conserving treatment is desirable, radical mastectomy remains the most appropriate surgical treatment for many breast cancer patients. The absence of breast can lead to deformities and defects in body shape, generate adverse negative emotions, and cause the messenger to suffer both physical and psychological blows. With the popularity of screening and increased awareness of self-care, breast cancer can be detected at a much earlier stage. Therefore, in recent years, breast cancer treatment not only focuses on improving the survival rate of patients, but also attaches great importance to breast reconstruction and its effect after resection. The rationale and timing of breast reconstruction, common reconstruction modalities and their advantages and disadvantages, and factors affecting reconstruction are reviewed.
1. Reasons for reconstruction
Women who undergo resection often suffer both physiological and psychological blows. The physiological blow for patients after radical resection includes systemic blow, partial or complete loss of breastfeeding function, loss of skin sensation in the chest, limitation of movement, affecting appearance and dressing problems. The psychological blow is, first, the worry about the cancer; second, the emotional ravages, including the feelings of physical disfigurement, loss of femininity and femininity associated with the absence of the breast. For some patients, the latter blow is heavier than the former and prompts female patients who have undergone or will undergo radical surgery to explore the possibility of breast reconstruction [1]. Postoperative breast reconstruction can reshape the body, improve vitality, restore femininity and sex appeal, and make patients feel they have a good quality of life. elder et al [2] prospectively studied the quality of life of breast cancer patients before and 12 months after mastectomy and immediate reconstruction, as well as expectations and satisfaction with immediate prosthetic reconstruction, using the SF-36 health questionnaire method scores. 76 cases The preoperative scores of the participants were lower than those of the general population of 920 participants of similar age, while at 12 months postoperatively all scores improved and were equal to those of the general population. Breast reconstruction can reshape the breast and ensure quality of life without compromising prognosis or postoperative breast cancer surveillance [2, 3].Murphy et al [3] reviewed 1444 patients after radical breast cancer surgery, 1262 in the non-reconstruction group and 182 in the reconstruction group
cases, including prosthetic reconstruction, autologous tissue reconstruction, immediate reconstruction and delayed reconstruction. After 10 years of follow-up, it was found that the local recurrence rate of breast cancer was similar in the reconstructed and non-reconstructed groups, and there was no significant correlation between post-resection breast reconstruction and local recurrence rate of breast cancer. Studies have shown that the choice of breast-conserving treatment is more a matter of physical aesthetics [4, 5]. Postoperative breast reconstruction is undoubtedly a good option for patients who fear that excision will affect their physical aesthetics but have to use it as one of the treatments for breast cancer. Therefore, postoperative reconstruction is both a medical and an emotional decision.
2.Timing of reconstruction
Reconstruction can be done immediately or postponed. Immediate reconstruction can improve the outcome of the revision and ease the negative emotions after excision. Postponing reconstruction gives the patient more time to make a decision. Al-Ghazal et al [6] conducted a retrospective analysis of 121 post-radical breast reconstruction patients and showed that immediate reconstruction significantly reduced anxiety and depression, and had significant advantages in terms of body image, confidence, sex appeal and satisfaction. Immediate reconstruction is more likely to reduce adverse feelings and enhance mental health. In addition, there is clear evidence that neither prosthetic nor autologous reconstruction has an impact on the incidence of accidents or monitoring of cancer recurrence [3, 7]. From a surgical perspective, immediate reconstruction preserves important anatomical structures such as the inframammary skin fold, has high skin extension of the breast, and achieves better revision results. Therefore, immediate reconstruction is more popular. There is also delayed-immediate reconstruction, which involves placing a tissue expander at the same time as the mastectomy to preserve the skin pouch of the breast, pending pathology results to determine if radiation therapy is needed. If radiotherapy is not required, the patient will undergo immediate reconstruction, and conversely, reconstruction will be postponed until after the completion of radiotherapy, preserving the skin capsule of the breast can achieve better reconstructive results.
3.Reconstruction methods
3.1 Prosthetic reconstruction The current prosthetic reconstruction methods include immediate reconstruction with standard or adjustable prosthesis, two-stage reconstruction with expander-permanent prosthesis, or combined prosthesis-autologous tissue reconstruction.
3.1.1 Immediate reconstruction with one-time completion implants is only suitable for patients who have small, non-sagging breasts with skin and muscle quality that is
good. The disadvantage is that the result of the revision is average and many patients need some adjustment. This reconstruction method is not widely used.
3.1.2 The expander is placed under the muscle (usually below the pectoralis major and serratus anterior) during the two-stage reconstructive excision of the expander-permanent prosthesis. The expander is continuously and regularly filled with saline on a weekly basis for expansion. Once the expander has filled to its target volume and the tissue has expanded sufficiently (usually 3-6 months or after the end of adjuvant therapy), the expander can be removed in phase II for placement of a permanent prosthesis. Two-stage expander-permanent prosthesis reconstruction has become the most common method of prosthetic reconstruction [8].
3.1.3 Combined prosthesis-autologous tissue reconstruction mastectomy removes a large area of skin, complex scarring and skin and muscle injured by radiotherapy to form a non-expandable capsule [9]. In the above-mentioned cases, there is no adequate skin-muscle pouch for expansion and a combined autologous tissue (usually a latissimus dorsi flap) can be used for reconstruction. The use of additional autologous tissue in prosthetic reconstruction prolongs the operative time, increases the complexity of the procedure and raises the risk of complications in the dorsal donor area. Therefore, combined prosthesis-autologous tissue reconstruction is usually only indicated for highly suitable patients.
3.2 Selection of permanent prostheses Permanent prostheses are classified by their shape, shell texture and filling material. There are two basic types of breast implants:saline implants and silicone implants. The most common shapes are teardrop or round. The shell of all implants is made of silicone and can be divided into smooth-surface implants and special surface implants. The specialty surface prosthesis is a leap forward in prosthesis technology that reduces the incidence of periosteal contracture. Compared to saline implants, reconstructed breasts with silicone implants are softer, feel more natural, and retain their shape better. There have been misconceptions and controversies about the safety of silicone implants for the past 20 years. Until November 2006, the US Food and Drug Administration concluded that silicone implants were safe and effective for general use in breast reconstruction, correction of congenital breast deformities, and cosmetic breast augmentation after years of rigorous multicenter clinical studies and retrospective analysis of multiple data [10]. It is now clear that silicone gel and breast implants are not carcinogenic and do not cause immune or neurological disorders or other systemic diseases [11-13]. The most likely risk is leakage of silicone into the local tissue [14]. Although this risk has not been established, patients who doubt the safety of silicone prostheses tend to choose saline prostheses.
3.3 Autologous tissue reconstruction Autologous tissue breast reconstruction involves the use of tissue from other parts of the patient’s body to reconstruct the queer breast to create a natural-looking breast projection.
3.3.1 TRAM flap technique transverse incision of the rectus abdominis flap (transverserectus
abdominismuscleflap (TRAM) consists of skin, subcutaneous tissue, and one or both rectus abdominis muscles and anterior sheaths, and is divided into a tipped TRAM flap and a free TRAM flap (also known as a free flap of the inferior abdominal wall artery perforator). The rectus abdominis muscle has a dual blood supply from the deep superior abdominal artery and the deep inferior abdominal artery, and the blood supply of the tipped flap comes from the deep superior abdominal vessels, whereas the free flap uses the deep inferior abdominal artery as the anastomotic vessel.
The blood supply of the tipped flap comes from the deep superior abdominal wall vessels, while the free flap uses the deep inferior abdominal wall artery as the anastomosis vessel. The tied muscle flap tissue migrates through the subcutaneous tunnel between the chest and abdomen to the breast quadrant. The free flap requires precise isolation of the deep inferior abdominal arteriovenous vessels within the rectus abdominis muscle, dissection of the vessels distally and anastomosis to the internal mammary or dorsal thoracic vessels. The transfer flap is reconstructed by safe and precise tailoring. The deficient rectus abdominis muscle is sutured to the anterior rectus abdominis sheath, using an artificial patch if necessary. After suturing the skin only a low horizontal scar remains in the abdomen and the umbilicus is reset on the corresponding skin [15, 16].
3.3.2 Limitations of using abdominal tissues Sufficient skin and subcutaneous tissues need to be available in the lower abdomen of patients reconstructed using abdominal flaps. In patients with thin bodies, abdominal flaps are not a good option. Contraindications to the use of abdominal flaps include a history of abdominal surgery such as abdominoplasty, liposuction, open cholecystectomy, or other major abdominal surgery that would reduce the skin and tissue volume of the flap or compromise the blood supply to the abdominal group. Other relative contraindications include obesity, smoking, history of thrombosis, and other serious systemic diseases.
3.3.3 Other Autologous Tissue Flaps Other autologous tissue donor areas include the back, buttocks, and thighs. Microsurgical techniques and equipment are required for thigh flaps, superior gluteal artery flaps, or inferior gluteal artery flaps. The latissimus dorsi flap has no microsurgical requirements, but the amount of reconstructed tissue in the latissimus dorsi flap is usually insufficient and requires joint reconstruction with a prosthesis.
4. Advantages and disadvantages
All reconstructive methods increase the risk of accidents compared to resection alone. Patients and their physicians must weigh the advantages and disadvantages of each method to make the most appropriate decision.
4.1 The advantages of prosthetic prosthesis reconstruction include shorter operative time (1 to 2 h), absence of donor scarring and complications. The obvious disadvantages are the prolonged time to reconstruct the breast crest and the need for multiple outpatient visits to complete expander expansion and a second surgery to complete prosthesis placement. Early complications include infection, hematoma, and prosthesis exposure [17], and late complications include capsular contracture, prosthesis leakage or rupture, infection, or other complications that may lead to prosthesis removal or replacement [18]. The complication rate is significantly higher in patients with a history of radiotherapy or those receiving postoperative radiotherapy [17-19]. For such patients, autologous tissue reconstruction is a better option. The final cosmetic result of prosthetic reconstruction is less than ideal, with the breast crest of the prosthesis being too round in shape and not creating a natural, slightly sagging breast, sometimes requiring contralateral breast revision surgery to improve bilateral breast symmetry. The most prominent advantage of autologous tissue reconstruction is a softer, naturally slightly drooping and more natural-looking breast crest in a single surgical procedure [20]. The TRAM flap is also used for cosmetic abdominal surgery. The disadvantages are longer operative time (5-10 h), more blood loss, longer recovery period, relatively high rate of necrosis of the transferred skin and subcutaneous tissue, and possible donor area
corresponding problems such as additional scarring, weakening of the abdominal wall, abdominal wall bulge, or incisional hernia [21, 22]. The tipped TRAM flap is simple and relatively short to perform, but has a large rectus abdominis defect and a correspondingly increased risk of incisional hernia or abdominal wall bulge. Due to the twisted tip, the blood supply is relatively poor and prone to flap necrosis and fat necrosis [23]. The main advantage of the free flap is that less donor muscle needs to be obtained, enabling the use of autologous tissue while reducing complications. Free TAMP
flap, only a small portion of the rectus abdominis muscle is used, whereas the tipped TRAM flap requires almost a whole rectus abdominis muscle. Free flaps usually achieve better reconstructive results because there is no excess muscle in the subcutaneous tunnel between the chest and abdomen [22]. The free flap has a better blood supply, which helps to reduce fat necrosis [23]. The disadvantages are that free tissue transfer increases operative time, and vascular anastomosis requires microsurgical techniques and equipment and carries the risk of thrombosis.
5. Completion of reconstruction
5.1 Nipple-areola reconstruction Nipple-areola reconstruction can restore the realistic and natural shape of the breast. With the increase in nipple-areola preservation during radical surgery and advances in reconstruction techniques, post-radical breast reconstruction is more aesthetically pleasing than breast-conserving surgery.A recent study by Cocquyt et al [24] showed that immediate skin-preserving inferior abdominal artery perforator free flap reconstruction or TRAM flap reconstruction provided better revision results than breast-conserving treatment. Nipple-areola reconstruction is usually performed about 3 months after breast reconstruction, after both breasts have achieved stable symmetry, and includes remodeling of form and color. A naturally raised nipple is usually created using the top tissue of the reconstructed breast, and nipple-areola coloring can be accomplished using a tattoo technique after the wound has healed.
5.2 Revision Surgery Many reconstructed breasts do not have the same shape and size as the contralateral breast, and revision surgery can improve the appearance of the reconstructed breast and bilateral breast symmetry. Orthodontic surgery can be completed at the same time as nipple-areola reconstruction. Revision surgery also includes lifting, reduction, and enlargement of the contralateral breast.
6.Radiotherapy problem
For breast cancer patients who need to receive radiotherapy, prosthesis reconstruction is not a good choice. Radiotherapy can affect wound healing and cause loss of tissue volume [25]. Tissues affected by radiotherapy are usually difficult to expand, and the risk of infection, need for expansion, and exposure of the prosthesis will be increased [26]. Therefore, breast reconstruction after radiotherapy is best performed with autologous tissue.
Immediate autologous tissue reconstruction is not recommended for patients who require postoperative radiotherapy, and subsequent radiotherapy can have unpredictable effects on autologous tissue reconstruction. 102 breast cancer patients were studied by Tran et al [27] regarding the effect of radiotherapy on free TRAM flap reconstruction of the breast. 102 cases were enrolled, 32 in the immediate post-reconstruction radiotherapy group and 70 in the completed post-radiotherapy reconstruction group, with a mean follow-up time of Early complications included thrombosis, partial or total flap loss, skin necrosis, local
Early complications included thrombosis, partial or total flap loss, skin necrosis, and difficulty in local wound healing, while late complications included fat necrosis, flap tissue loss, and flap contracture. The results showed no significant difference in early complications between the two groups, while late complications were significantly different, with incidence rates of 87.5% and 8.6%, respectively, indicating that the effect of radiotherapy on flap reconstruction of the breast is long-term, and that reconstruction should be postponed until after radiotherapy is completed for patients who require postoperative radiotherapy. A proportion of patients who were not expected to require radiotherapy preoperatively but required radiotherapy based on the final pathology have completed immediate reconstruction. This does not mean, however, that the reconstruction was a failure. The impact of radiotherapy and the physical condition of the patient vary, and therefore the impact of radiotherapy on the final reconstructive outcome is inconsistent. Close follow-up is only required to detect complications in a timely manner.
7.Summary
The most common reconstruction methods are expander-prosthesis reconstruction and TRAM flap reconstruction, which offer women with breast deformity excellent options for reconstructing near-normal-looking breasts. The timing and method of reconstruction is determined by a number of factors, such as the shape and size of the original breast, the location and type of tumor, the availability of autologous tissue for reconstruction, age, the patient’s general condition, and the type of adjuvant therapy. The development of the reconstruction plan requires the participation of the patient and the oncologic surgeon, pathologist, and plastic surgeon, so that the patient can better understand the feasible approaches and make a formal and individualized choice. In practice, however, the final decision often depends on the patient’s preference. Patients who understand the characteristics of reconstruction methods and make individualized choices can achieve the best revision results, the greatest satisfaction, and the best quality of life [20, 28]. It is believed that breast reconstruction will become increasingly popular among patients and valued by physicians, and reconstruction methods will be further developed.