The severe physical and psychological trauma of breast loss after breast cancer surgery and the resulting negative impact on the patient’s confidence and ability to fight the tumor are receiving increasing attention from oncologists and plastic surgeons. Breast loss often causes depression, severe anxiety, marital disorders, and disruption of social activities. Currently, due to the advancement of comprehensive breast cancer treatment, the survival rate of patients after surgery has been greatly improved, and the continuous improvement of surgical procedures (modified radical breast cancer surgery with preservation of nipple and areola) has provided more favorable conditions for breast reconstruction after breast cancer surgery, especially immediate breast reconstruction.
Breast reconstruction (breastreconstruction) refers to the reconstruction of breast wall deformities and breast defects caused by mastectomy due to breast disease using autologous tissue grafts or breast implants. The surgical method is divided into breast implant and autologous tissue transplantation.
The basic requirements for breast reconstruction include reconstruction of the breast crest, symmetry of both breasts and reconstruction of the nipple areola.
Breast and chest wall deformities after breast cancer surgery are classified into four categories: partial breast deformity, breast gland deformity, breast deformity, axillary depression deformity and breast and pectoral muscle deformity, axillary and subclavian depression, and loss of anterior axillary fold deformity. Accordingly, suitable reconstruction methods can be used.
Common breast reconstruction methods include: (1) single capsule implantation; (2) adjustable double capsule implantation; (3) stage I soft tissue expansion + stage II implantation; (4) latissimus dorsi muscle flap; (5) transverse rectus abdominis (TRAM) muscle flap; (6) inferior abdominal wall artery perforator (DIEP) flap; (7) combined application of rectus abdominis and latissimus muscle flap. However, the final method of reconstruction should be decided according to the condition of the scar, skin, pectoralis major muscle, subclavian area and axillary defect on the affected side and the morphology, fullness and sagging, age, abdominal and back scars of the healthy side of the breast.
The conditions for immediate breast reconstruction for breast cancer patients in our hospital are: (1) pathologically confirmed breast cancer with TNM stage 0 to II; (2) patients who cannot or do not want to undergo breast-conserving breast cancer surgery, have a requirement for breast reconstruction and voluntarily undergo immediate breast reconstruction; (3) for those who undergo TRAM breast reconstruction, there should preferably be no surgical incision in the lower abdomen (except for appendiceal myectomy); (4) there are no contraindications to surgery.
The timing of breast reconstruction is divided into immediate breast reconstruction and late breast reconstruction. Traditionally, it is believed that breast reconstruction should be performed 1 to 2 years after surgical excision of breast cancer for those without signs of recurrence. Currently, it is considered that second-stage breast reconstruction should be performed 3 to 6 months after the 1st surgery, i.e. after the completion of chemotherapy. In the case of patients who need radiation therapy after breast cancer surgery, it is advisable to perform it 6 to 12 months after the cessation of radiation therapy, after the skin and subcutaneous scars have softened after radiation therapy, or when they “tend to soften”.
As research progresses, it is proved that breast reconstruction at the same time as radical breast cancer surgery is safe and feasible, and there is no difference in terms of complications, cancer recurrence rate and death rate compared with radical breast cancer surgery alone, and the local recurrence rate after breast reconstruction for stage I and II breast cancer is less than 5%. Currently, in Europe and the United States, about 60% of patients undergo breast reconstruction at the same time as breast cancer removal. Therefore, the timing of breast reconstruction is no longer the main factor affecting breast reconstruction, and immediate breast reconstruction has shown an increasing trend in recent years. On the other hand, there is a recovery process after any surgery, and in clinical practice, few patients request reconstruction within 3 months after radical breast cancer surgery. It is generally believed that patients with stage I and II breast cancer can undergo breast reconstruction at the same time as the removal of breast cancer, or late reconstruction six months after radical surgery. The advantage of immediate breast reconstruction is that patients need only one surgery and do not experience breast deformation after surgery and suffer less mental pain. The advantage of post-reconstruction is that the patient has personal experience with the breast defect and can make a rational judgment on whether to request breast reconstruction, and has a higher level of post-operative satisfaction. The disadvantage is that two surgeries are required and the cost is higher than for immediate reconstruction.
All patients for breast reconstruction, especially after breast cancer surgery, must be physically healthy, emotionally stable, free from mental and psychological disorders, free from the risk of cancer recurrence, and the contralateral breast is healthy and free from malignant tumors.
Breast reconstructive surgery should include: (1) Breast reconstruction should first address the repair of skin loss. The repair of skin loss can be done by applying tissue expanders to expand the skin and increase the area of the skin; using local flap transfer repair, including retrograde or rotational flap grafting of the upper abdomen; using abdominal flap or skin tube transfer, latissimus dorsi muscle flap grafting, rectus abdominis muscle flap grafting, and microsurgical free flap grafting. (2) The hemispherical shape of the breast should be shaped at the same time of breast skin repair, or at a certain period after the repair, including the application of myocutaneous flap graft, prosthesis graft, etc. (3) After radical breast cancer surgery, there is often a lack of anterior axillary wall and subclavian hollow area, which need to be reshaped, and often myocutaneous flap grafting is used for repair. (4) Reconstruction of nipple and areola. (5) Correction of bilateral breast asymmetry.
Breast reconstruction surgery and its characteristics
Selection of breast reconstructive surgery after breast cancer surgery: We have learned that the selection of breast reconstructive surgery after breast cancer surgery should follow the following principles: (1) the appropriate surgery should be selected according to the degree of destruction of breast and chest tissues and the amount of tissue loss (especially whether to preserve breast skin and pectoral muscles) by radical breast cancer surgery and postoperative radiotherapy; (2) when selecting flap transfer surgery, the destruction of the donor area and the occurrence of complications should be minimized; (3) the relationship between the donor area and the breast reconstructive surgery should be minimized. (3) the treatment of both donor and recipient areas should follow the cosmetic principle; (4) according to the conditions of the operator’s medical institution and his or her own technical level, it is better to choose a simple, easy, safe and reliable procedure than a complicated one.
Transverse inferior insular rectus abdominis muscle flap (hereinafter referred to as TRAM) for breast reconstruction
It can meet the requirements of almost all types of breast reconstruction, with a certain degree of fullness and sagging, and can achieve complete symmetry with the healthy side, as well as the effect of slimming. Indications: (1) immediate breast reconstruction after modified radical mastectomy; (2) second-stage breast reconstruction after radical mastectomy; (3) breast reconstruction for congenital breast dysplasia; (4) reconstruction of breast defects after mastectomy by mistake; (5) reconstruction of traumatic breast defects. Contraindications: (1) after a transverse abdominal incision has been performed in the quarter rib area, or after a transverse abdominal incision in the lower abdomen; (2) after a median incision or median incision next to the lower abdomen; (3) after radical treatment of breast cancer, where the ipsilateral internal thoracic artery has been ligated and a TRAM flap graft cannot be performed ipsilaterally.
This procedure can provide a huge myocutaneous flap with good blood flow and is suitable for middle-aged and elderly people with more tissue defects and a more lax abdominal wall. Traditional radical surgery often results in total loss of breast skin and pectoral muscle and often has scar tissue with poor blood flow, tightness and lack of elasticity, especially in those who have undergone local radiation therapy, and poor quality and quantity of tissue in the recipient area.
TRAM is the flap that provides the largest amount of tissue of all the flaps available for breast reconstruction, so this procedure should be preferred. This procedure can be accomplished by transferring the flap with the tip, or by free grafting with microsurgical techniques. The single-tipped graft can be divided into single-tipped and double-tipped. Therefore, a double-tipped TRAM is now used, using the rectus abdominis muscle and the arteries and veins on the abdominal wall below it as the tips, which has more reliable blood flow and can improve the success rate.
This procedure also has a postoperative scar consistent with abdominoplasty, which has a cosmetic effect on the flaccid abdominal wall while playing a role in abdominoplasty and is readily accepted by patients, but is contraindicated in those who are thin, have not had children, have a tight abdominal wall, have chronic cough and constipation. A common complication is abdominal wall hernia, but this complication can be effectively avoided by taking care to cut the anterior sheath and rectus abdominis muscle above the semicircular line and carefully repairing the defect during surgery.
Breast reconstruction using microsurgical techniques
In other words, free flaps and myocutaneous flaps are used to reconstruct the breast. The donor areas available are: free upper gluteal muscle flap, contralateral latissimus dorsi muscle flap, TARM, greater omentum, lower abdominal wall or inguinal flap, lateral thigh and medial thigh transverse flap, etc. Although microsurgery is a new way of breast reconstruction, it is technically necessary to have a skilled and professional team of microsurgery, plus postoperative radiotherapy often causes some damage to the blood vessels in the recipient area, and many myocutaneous flaps have a limited length of free vascular tip, which increases the difficulty of the operation, and the risk of free flaps is much greater than that of tipped flaps. Therefore, most plastic surgeons only use this flap as a last resort when breast reconstruction cannot be achieved with other methods, or in specialized institutions with a high level of surgical expertise.
Breast reconstruction by transfer of the latissimus dorsi muscle flap
The latissimus dorsi muscle is fed by the thoracodorsal artery and has good blood flow. It can provide more tissue volume, and the tip can be narrowed to 3-5 cm, which is convenient for transfer. Indications: (1) Breast reconstruction similar to rectus abdominis muscle flap; (2) Breast reconstruction with latissimus dorsi muscle flap after radical breast cancer treatment, and repair of anterior axillary folds and subclavian space. Contraindications: (1) the latissimus dorsi muscle has been severed after thoracic surgery; (2) the thoracic dorsal artery has been ligated after radical breast cancer surgery; (3) the thoracic dorsal artery has been destroyed after radiation treatment for breast cancer. The advantage of this procedure over the rectus abdominis muscle flap for breast reconstruction is that the muscle flap has good blood flow and can be used to reconstruct the breast with the flat and wide anatomical features of the muscle flap, and at the same time, it can fill in the hollow depressions of the subclavian and anterior axillary folds caused by radical surgery. dermatitis, etc.), the latissimus dorsi muscle flap should be preferred. The disadvantage of this procedure is that in most cases, the amount of tissue is still insufficient to fully meet the needs of breast reconstruction, and a breast prosthesis can be placed under the latissimus dorsi muscle to compensate for the lack of tissue and increase the cosmetic effect.
Breast reconstruction with prosthesis filling
Indications for surgery: (1) clinical TNM stage 0 to II; (2) patients with breast reconstruction requirements; (3) no sagging of the healthy side of the breast or within II degree of breast sagging, and no contraindications to surgery; (4) applicable to breast Chinese Journal of Breast Diseases (ElectronicVersion) January 2007, No. 1 trial issue ChinJBreastDis (ElectronicVersion). January2007,No1 Modified radical surgery for breast cancer with good tissue coverage and retention of pectoralis major muscle; or combined with other tissues; (5) Other indications are the same as TRAM. this procedure is the most simple and easy to perform, but there needs to be sufficient skin and pectoralis muscle locally, if there is a lack of pectoralis muscle and the prosthesis is placed directly under the skin, it will probably produce severe fibrous wrapping, and eventually due to fibrous capsular contracture, the Therefore, it is only suitable for breast tumor patients who have preserved most of the breast skin (especially nipple and areola) and pectoralis major muscle for immediate breast reconstruction. Once a recurrence is detected, the prosthesis can be removed and corresponding treatment can be carried out, but the indications should be strictly mastered, and it should never be removed palliatively to make reconstruction convenient. If the local tissue tension is too high, the local tissue can be expanded with skin expanders first, and after 4-6 months, the expanders can be removed and replaced with silicone gel breast prosthesis or reconstructed with adjustable prosthesis.
Reconstructed breast with adjustable prosthesis
Scope of application: Applicable to all surgical ranges of single capsule prosthesis, and suitable for patients with large breasts (volume >250ml) and patients with more skin defects during radical breast cancer treatment (Bostwick method tissue defects >5cm). METHODS: An adjustable double-capsule silicone gel-saline prosthesis was placed behind the pectoralis major muscle at the same time as the modified radical mastectomy for breast cancer. A water injection valve was buried under the skin, and the reconstructive surgery was completed by injecting the appropriate volume of saline. Two weeks after the surgery, saline is injected percutaneously into the prosthesis in stages to expand the skin until both breasts are symmetrical.
If the contralateral breast is sagging and is not symmetrical with the reconstructed breast after surgery, contralateral mammaplasty is required. For cases with nipple areola deficiency, nipple and areola reconstructive surgery can be considered 3 months after breast reconstruction.
With the increasing understanding of clinical characteristics and biological behavior of breast cancer, comprehensive treatment based on surgery has become a more mature treatment mode, and early detection and treatment of breast cancer in turn enables long-term survival of patients. However, surgical removal of one or both breasts causes serious physical and psychological trauma and pain to the patient. Therefore, it is still necessary to treat the psychological trauma while treating the disease, and surgical oncology that not only removes the tumor completely but also preserves the tissues and functional reconstruction is a necessary path for future development.