Short Notes in Plastic Surgery

September 5, 2017

64. Postmastectomy reconstruction of the breast

Filed under: Chapter 64,Uncategorized — ravinthatte @ 7:08 am

This chapter was written with the help of Prashant Govilkar a consultant plastic surgeon in the United Kingdom and Bijoy Methil a consultant plastic surgeon in Mumbai India.

  1. The breasts are a very important and overt feature of a woman’s sexuality. In addition, the fact that the organ is used by her to feed her offspring means that the breasts are a vital part of her biological persona. What is more the shape of the breast mound as well as its projection together with the nipple areola complex from the chest wall has been considered the most attractive and beautiful part of the human female anatomy. In none of the other mammals in the animal kingdom does the breast project in this fashion. In the event the breasts have been the subject of many an artists’ drawings paintings and sculptures. The breasts have also been dressed by a variety of clothes which covered them tightly to minimise their sexual appeal or were left partly exposed ostensibly for their titillatory effect. The corset for example flattened the shape of the breasts and at the other end the under wired brassiere not only lifted them but also facilitated a maximum show of the cleavage (décolleté). It has been alleged that wardrobe malfunctions of female public performers exposing parts of their anatomy may not always be accidental and is not necessarily frowned upon by the ladies in attendance. All in all this has been a vexed subject for millennia.

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  1. Alas the female breast is also one of the most frequently visited organ by the emperor of maladies and the number of cases of cancer of the breast show no signs of abating partly because more cases are recognised than in the past on account of increased awareness. The absolute numbers might be rising as well because of a variety of factors which include late pregnancies, lack of breast feeding, a faulty lifestyle, obesity, environmental pollution and radiation from electronic equipment.
  2. The treatment of cases with cancer of the breast till the middle of the last century was an exceedingly radical form of surgery which included removal of the breast together with the nipple areola complex and a large portion of the surrounding skin, the pectoralis major muscle and a total clearance of all the axillary lymph nodes and occasionally removal of supraclavicular lymph nodes as well. Sometimes in advanced cases so much skin was removed that the wound could not be closed primarily and a skin graft had to be placed on an unfavourable bed. The patient was also subjected to a large and crude form of radiation. During those years reconstruction of the breast mound was virtually unknown though one of the earliest recorded use of a pedical muscle flap (latissimus dorsi) was for re construction of the breast mound (please see history of muscle flaps in the chapter (58). For the most part women suffered their post mastectomy deformation in silence or had to make do with stuffing their brassiere cup with some soft material. Today some excellent external soft prosthesis built in the brassiere are available for those women who opt not to undergo surgery to reconstruct the breast or for those women who are going through courses of radiotherapy and chemotherapy and are awaiting a surgical reconstruction of the breast mound.

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  1. After the era of radical surgery there was a phase in the seventies of the last century in which many women were subjected randomly to a soft tissue radiography with or without radiopaque nuclear dyes to diagnose the condition and many women were subjected to a sort of prophylactic or early mastectomy based on mere suspicion with or without what would now be considered as a ‘full proof diagnosis’. Some of these surgeries were also performed for what were labelled as ‘premalignant lesions’. Many of these women also underwent reconstruction with breast implants till questions came to be raised about the ethicality and the scientific basis of these treatments.
  2. Presumably we know a lot better now notwithstanding the old philosophical adage that in making scientific progress we move from one stage of ignorance to another. Here is how the situation has changed.
    1. There is widespread awareness now about the condition as compared to the past and all types of media have played a laudable role in this transformation. Many women now know the method of self-examination and this has resulted in many an early diagnosis. The media has also done a creditable job of publicising the life stories of what are called as “survivors”. A combination of early diagnosis and an optimistic patient is a ‘sea change’ from an earlier belief that cancer meant certain death and a far better informed and cooperative patient is now more a rule than an exception.
    2. The ‘hormone dependency or sensitivity’ of the tumour is now much better understood and therefore ancillary surgeries such as oophorectomies for pre-menopausal oestrogen dependent tumours or drugs to reduce the oestrogenic activity in their treatment have changed the nature and extent of surgery. The prognosis of a given case is also easier to predict and the schedule of chemo as well as radio therapy can be planned in advance and the patient can be informed as to when reconstruction of the breast mound can be undertaken.
    3. The technique of C.T or ultra-sound guided trucut core biopsy has improved considerably and a diagnosis of not only the malignant nature of the tumour but also its biological behaviour vis a vis its hormone dependency is now available pre-operatively. The concept of a formal biopsy of the sentinel node in the apex of the axilla and the conclusions drawn from it about the need for an axillary lymph nodular dissection has allowed a far more limited form of surgery leading to terms such as ‘lumpectomy’ or ‘skin saving surgery’. This has meant that an immediate reconstruction following the removal of the tumour is now possible if the margins of the excision are clear and the sentinel node is also negative for the spread of the tumour in the axilla .If the sentinel node biopsy is positive, then axillary node clearance together with the breast surgery may also be followed by immediate reconstruction.
    4. A sort of revolution has occurred in the treatment of breast cancer thanks to the science of genetics. The unusual prevalence of cancer of the breast in certain families had been known for some time. Women and even girls have now the advantage of genetic investigations and can be warned that they have inherited the culprit gene and some women are now opting for a prophylactic sub cutaneous mastectomy followed by immediate reconstruction with breast implants or other modes of reconstruction with flaps. An ethical debate is also now on as to at what age girls should be informed of their genetic predisposition because there is no way of knowing when and if the disease will strike.

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  1. The plastic surgeon when asked to reconstruct the breast, mentally divides his task in three parts namely, creation of the breast mound, the recreation of the nipple areola complex and achieving symmetry with the opposite unaffected breast. When aiming for symmetry it is usually the case that the unaffected breast is pendulous on account of age and the usual practice is to create a normal mound on the affected side and then offer a reduction in size on the normal side. However, an occasional patient might demand that the new breast should resemble the ptotic un affected breast. Photographs of patients with both these scenarios are reproduced below

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The techniques of Reduction mastoplasty are not a part of this chapter and will be covered in a different chapter. However, if the unaffected breast appears smaller than the affected reconstructed counterpart, a suitable sized breast implant can be used for that breast to achieve symmetry As to the recreation of the nipple areola complex the procedure is usually undertaken after the new breast mound has settled down and this subject is covered at the end of this chapter.

  1. Irrespective of whether the reconstruction is undertaken immediately after surgery or is delayed, three options are available to the surgeon (a) a breast implant (b) transfer of living tissue with a pedicle or by way of microvascular free tissue transfer to recreate a new breast mound or(c) a combination of both.
  2. For a breast implant to succeed an adequate skin envelope is essential. This ideally happens when a prophylactic mastectomy is performed in which the skin is completely spared including the nipple areola complex and only the breast tissue is removed. In these patients, an implant can be introduced with some difficulty through an incision in the areola which might have been used to perform the mastectomy. If the implant is to be introduced in the sub-pectoral plane then an incision in the axillary fold or a sub-mammary incision may be preferred. Photographs of a patient with breast implants after bilateral prophylactic mastectomy have been included in para 5d. In cases where skin sparing surgery has been performed and the wound has been closed primarily a judgement has to be taken as to if the available skin can be expanded by a tissue expander to ultimately accommodate a breast implant. This tissue expander as well as the breast implant to be placed later is in almost all the cases placed in the sub-pectoral plane to avoid direct pressure on the skin envelope. In most cases where skin sparing surgery has been performed the pectoralis too is usually spared. The access for the introduction of the expander is usually located at a distance from the scar on the breast on the lateral side near the anterior axillary fold and a sharp dissection is avoided and the cavity is usually created with the fingers. Some of these patients have received radiation which is one more reason not to handle the skin envelope. It is a matter of judgement as to if only an implant is the best form of treatment or should tissue be imported and an implant then placed under the imported flap.

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  1. There are a variety of options available for recreating the breast mound. The pedicled lattisimus dorsi (L.D.flap) flap supplied by the thoraco-dorsal division of the subscapular artery a branch of the third part of the axillary artery is extremely convenient and popular because it is in the vicinity and easy to transfer and the resultant defect on the back can be closed by undermining the skin. The muscle provides the bulk and it can carry a sizable island of skin which can suffice to compensate for any shortage of skin in the recipient area of the breast. In anticipation or as a result of any loss of muscle mass, this flap can easily accommodate a breast implant even in cases where in the original surgery the pectoralis muscle had been removed. See illustrations below.

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  1. Perhaps the most suitable site for transfer of tissue to substitute for partial or complete loss of breast tissue is the lower abdomen from around the umbilicus up to the line of the pubic hair. The colour of the skin in this area is a good match for the skin on the breast, both areas being covered for most part of life and the soft consistency of the fat in the lower abdomen matches that of the breast tissue. In parous women, this tissue is usually in excess and when transferred leads to no deleterious effects. In fact, the closure of the wound after the tissue has been transferred is very easy and the result in an earlier lax abdominal wall is welcome by almost all women. Two diagrams describing this flap are printed below followed by clinical cases and then a paragraph which details its evolution towards a free microvascular flap.

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  1. This lower abdominal tissue spread transversely has a dual blood supply. The more tenuous supply comes from above by way of the deep superior epigastric artery which is a continuation of the internal mammary artery also called the internal thoracic artery which in turn is a branch of the subclavian artery. The superior epigastric artery runs its course through the rectus muscle from which it sends perforators to supply the skin and these are more numerous in the upper abdomen than the lower. In the lower abdomen the corresponding artery is deep inferior epigastric artery a branch of the external iliac artery which enters the muscle from below and runs its course also through the rectus muscle running its course superiorly but its length is shorter and its perforators through the rectus muscle supplying the adjacent skin are more profuse in the lower abdomen than that of the superior epigastric artery. The idea of carrying skin of the lower abdomen as a pedicled flap based on the rectus muscle as a carrier and the superior epigastric artery as a source of blood supply is quite ingenious but requires the sacrifice of a considerable length of the rectus muscle. In fact, a flap based on this artery and its perforators in the upper abdomen was described earlier but fell into disuse probably because of two reasons. For one the skin and the subcutaneous in this area was not quite enough and of the same consistency as of the breast and the other being the closure of the defect after the flap was harvested left a scar in that part of the abdomen which is uncovered in many outdoor activities. It is on this background that a lower abdominal flap based on the deep inferior epigastric artery came to be described and used as the understanding of the vasculature in this area improved. Its disadvantage (if at all) was that the flap has to be transferred as a free microvascular flap which takes some time and is therefore not favoured for an immediate reconstruction a decision in which the oncologist and the anaesthesiologist play a part. As the time taken for micro-surgical procedures reduces and more and more surgeons become proficient in the technique the situation may change over the years. However, for creating a partial or a complete breast mound secondarily this flap is by far the best for more than one reason. The deep inferior epigastric (DIE) artery flap does not entail the loss of a considerable length of the rectus muscle as in the pedicled flap but involves taking only a small cuff of muscle from which its perforators emerge. The artery’s size as it takes off from the external iliac vessel is sizable and is therefore easy to anastomose. There has been a further modification in fashioning this flap in which sizable perforators of the deep inferior epigastric artery as they emerge from the rectus muscle are employed as the donor or source vessels eliminating the need of sacrificing even a small part of the rectus muscle. The fact that the lower abdominal wall below the crural line is vulnerable to herniation is well known because the fascia in this area is not as tough as it is in the upper two thirds of the abdomen. The harvest of the rectus muscle in the pedicled flap therefore required bolstering of this part of the lower abdominal wall sometimes with a synthetic patch. That need is eliminated completely in the perforator based flap which in its full form is called the deep inferior artery perforator flap (DIEPF).

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Photographs courtesy Prashant Govilkar

  1. One more flap needs to be mentioned here. This flap involves harvesting tissue from the upper two thirds of the buttock the consistency of which is about the same as the breast tissue and the closure of the resultant defect is easy because of lax skin. The scar also remains hidden even in a skimpy swim-ware. The flap is supplied by the superior gluteal branch of the posterior division of the internal iliac artery and it emerges between the gluteus maximus and the medius just above the upper border of the pyriformis muscle. The vessel is sizable in diameter and easy to anastomose.

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The approximate dimension of the tissue that can be harvested is shown in faint yellow. The artery emerges in to the subcutaneous tissue in the upper part of the buttock

  1. There are innumerable free flaps described to reconstruct a post mastectomy defect but the ones mentioned above are the most frequently employed. One flap based on the deep external iliac vessel which supplies the skin as well as the fat adjacent to the anterior superior iliac spine and the iliac crest and which usually bulges as age advances is also employed for post-mastectomy reconstruction. The volume of tissue here is not very large and the flap therefore can be used only for small breasts.

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  1. Irrespective of what flap is used, the art of the craft lies in placing the flap suitable to the axis of the defect and to gauge its depth which determines the volume. The pedicled flaps such as the LD or the Tram flaps have to be transferred subcutaneously and the greater the volume the wider is the undermining of the bridge of skin under which the flap is transferred. This has to be anticipated in advance.
  2. Experience has taught the plastic surgeons to map the lower abdominal flap’s vascularity into diminishing zones irrespective of whether the flap is based on the rectus muscle or the deep inferior epigastric artery or its perforators. The vascularity is best where the vessel (or vessels) enter the flap, is somewhat diminished in the adjacent zone near the midline on the contralateral side, is further diminished in an area adjacent to the area of the point of entry of the blood vessels on the ipsilateral side and the zone farthest from the midline on the contralateral side has the least blood supply. This part of the flap may often be deepithelialised to be buried during the reconstruction to supply bulk or may even be sacrificed to avoid possible necrosis but if used is placed in the shallow area of the defect usually on the lateral side (Please see figures below para ten.) Either of these flaps, (pedicled or free microvascular) can safely accommodate a breast implant underneath them if the volume of reconstructed breast is inadequate and if the pectoralis muscle has been excised. Ideally the transferred flap is fixed to the underlying tissue (pectoralis major when present) or whatever tissue is present so that it does not slide down.
  3. Lastly the treatment of the umbilicus requires to be explained. Any operation which takes away such a large part of the lower abdominal tissue and is then closed as in a lower abdominal abdominoplasty means that the umbilicus needs to be placed in a reasonable position higher up in or near the centre of the abdomen and not be pulled down with the movement of the upper abdominal flap. The umbilicus is therefore cored out of the skin flap and is left attached to it’s stock in the anterior abdominal wall and is brought out of the upper abdominal flap by making a hole at the desired point and the fixed with sutures.
  4. As mentioned at the beginning in this text the creation of a nipple and the areola is usually performed after the breast mound is created and allowed to stabilise. There are several methods described for this purpose but the most frequently used is the one in which the areola is created with skin from the groin or rather the medial side of the thigh posteriorly near the tapering part of the labia majora. The graft is full thickness in nature and the resultant defect is closed primarily. In a bilateral case the graft is usually harvested from the opposite side so that each defect can be closed primarily without difficulty. The harvest of the graft is performed after the nipple is created so that the exact defect is known. For the creation of the nipple three triangular flaps are marked around a point at which the nipple is to be created. These flaps are equidistant from each other with their broad bases towards the centre. Only the central one third of the flaps are left attached to their beds and the flaps are cut on all it’s sides and undermined. These cuts are enough to raise the flap in a V Y procedure, (in a three dimensional kind of way) and the broader parts of the flaps are lifted and sutured to each other with enough projection to mimic a nipple. The area surrounding the reconstructed nipple is then marked approximately equal to the areola on the opposite side and is excised on which the full thickness graft is carefully sutured and a tie over dressing is given but with an opening for the newly constructed nipple so that it can be observed post-operatively.

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Addendum by Prabha Yadav and Saumya Mathews, Tata Memorial Hospital, Mumbai:

Nature’s ability not only to recreate but to exactly replicate living tissue over millions of years boggles the mind though it too is a product of nature.

But hidden within this grand design are also sudden, major and subtle variations. The former leads to a paradigm species shift. The latter is probably a local accident. Anatomists and surgeons have painstakingly identified them over the last two centuries. With the arrival of newer technologies it is easier to pin point these variations ahead of surgery and can aid the surgeon in modifying his plans. The transverse abdominal flap based on the perforators of the deep inferior epigastric artery (DIEPF) is a case in point. The safety zones in this flap can now be ascertained more precisely by computerised tomographic angiography. This can later be confirmed on the table by the naked eye. The DIEPF flap appears now to have become the work horse for reconstruction of the breast and this investigative option would be worthwhile to be noted in this chapter.

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