There is significant variation in the number of revision surgeries required following primary breast reconstruction and this varies according to reconstruction type, number of breasts reconstructed, previous treatment such as radiotherapy, and patient factors such as diabetes, smoking, and obesity. For example, Losken et al reviewed nearly 900 patients after breast reconstruction, with an average of 4 revision procedures for unilateral reconstruction, and 5.5 for bilateral reconstruction being required,1 whereas Enajat et al reviewed more than 300 patients following free tissue breast reconstruction, with an average of 1.06 revision procedures per patient.2 Revision of the reconstructed breast can be undertaken for a variety of reasons including aesthetic appearance, implant problems, and soft tissue changes after adjuvant radiotherapy. What is important to stress to all breast reconstruction patients preoperatively is that they should expect to need more than one procedure in total for the initial reconstruction to be completed, and those undergoing implant-based reconstruction should expect further surgery to be needed in the longer term for management of capsular problems or implant replacement. In terms of unilateral autologous reconstruction, patients will often need two or three procedures to achieve optimal symmetry. Typically, the primary procedure involves transfer of tissue to the breast to provide a skin envelope and volume filler. The second procedure typically involves revision to the contralateral breast with perhaps a mastopexy or reduction with or without subtle ipsilateral alterations such as fat transfer or scar/shape alteration and perhaps donor site revision. The third stage would normally involve recreation of the nipple-areola complex under local anesthetic. In terms of patient satisfaction, autologous reconstruction patients tend to have higher satisfaction rates than implant reconstruction.3 It is important to discuss rippling and palpability of the implant post reconstruction and while this is a common problem it is not uniformly seen as it depends on other factors such as the thickness and quality of the overlying soft tissue envelope. The medium- to long-term risk of capsular contracture is likely to be between 10 and 15% rather than 35% in implant-based reconstruction.
Blondeel et al wrote a seminal paper describing the breast footprint, soft tissue shape and volume (conus), and skin envelope.1 These principles can be applied to secondary breast reconstruction to guide decision-making and surgical planning. It is helpful to think about the breast in this way so that reconstructive tools can be tailored to specific problems. For example, in patients who have undergone a standard mastectomy, there will be both a skin envelope and soft tissue deficiency. There may also be distortion or changes to the breast footprint secondary to surgery, scarring, or radiation changes. In a patient who has chronic problems after implant-based reconstruction, where a significant capsular contracture has occurred, there is likely to be a reduction in the breast footprint, which will need to be addressed. There may also be an apparent volume deficiency, or it may be that the volume is simply located in the wrong place. For example, if there is a double-bubble deformity. Like with any building structure, there must be a solid foundation to build upon, and in the breast, this refers to both the chest wall on which the breast sits and the breast footprint. Although the chest wall is not part of Blondeel’s three, it is vital to consider this and discuss things preoperatively with the patient. For example, where there is pectus excavatum or chest wall asymmetry, the result will be affected. In most secondary breast reconstruction, the breast base will need adjustment, to reset the footprint at the correct place on the chest and with the correct dimensions. Then the appropriate volume can be found and the skin envelope created accordingly. The nipple-areola complex is not one of the three components in Blondeel’s description although it does, of course, form part of the skin envelope and would ideally be located on the most prominent point of the breast mound. The key parts of Blondeel’s description are as follows (Figs. 59.1 and 59.2)2: 1. Footprint (Outline of breast on the chest wall) • Lateral: 1–2 cm behind anterior axillary line • Inferior: Inframammary fold • Medial: Within 1–2 cm of sternal midline • Superior: Cranially curved line connecting medial and lateral, most superior at midclavicular line 2. Soft Tissue (Conus) • Three-dimensional shape and volume of breast • More fullness inferiorly • Most projection at nipple-areola complex 3. Skin Envelope • Functions to hold the breast parenchyma in place • Excess skin results in breast ptosis • Skin shortage results in flattening of the breast • Skin quality also critical to maintaining shape and position Inframammary fold 6th rib 1st rib A B C Gland Level of inframammary fold Footprint of breast on chest wall Fig. 59.1 Frontal (A), axial (B), and sagittal (C) views of the breast footprint on the chest wall as described by Blondeel et al. Inframammary fold 6th rib 1st rib A B C Gland Footprint of breast on chest wall Skin envelope Conus Gland Fig. 59.2 Frontal (A), axial (B), and sagittal (C) views of the breast footprint, conus, and skin envelope as described by Blondeel et al.
There may often be some subtle volume differences between the breasts after unilateral autologous tissue reconstruction. Sometimes there is more volume on the reconstructed side and sometimes on the contralateral side. This can be affected by wound healing and if, for example, there has been some flap loss due to fat necrosis laterally then volume would be reduced. Decision-making for symmetrizing surgery will therefore depend on the patient’s preferred volume and shape characteristics of each breast. In cases such as this, an incision at the end of the previous skin paddle may be used to allow reduction of both skin and fat volume directly without creation of additional scars. Use of tailor tacking is useful to gauge resections required. Sometimes it is also necessary to perform liposuction to further refine symmetry. If there is no skin excess this can be performed as the only intervention. Although it may be reasonable to perform a formal mastopexy or low volume reduction to improve symmetry, it is not required for this deep inferior epigastric perforator (DIEP) reconstruction especially as the nipple areola has not yet even been reconstructed. In some situations, patients may prefer to have additional volume placed into the contralateral breast and fat transfer may be considered. However, this will result in fat necrosis being present in the breast and will need to be taken into account in subsequent mammography examinations.1–3
The use of fat transfer in breast reconstruction has massively expanded in recent years. It can be very useful for adding volume or correcting contour irregularities. Furthermore, it can improve the quality of tissues treated with prior radiation. It is used in both autologous and implant-based techniques. In the latter, the primary aim is to increase the ratio of natural tissue to prosthesis and increase thickness of the soft tissue envelope. In all cases, it is important to advise patients that multiple treatment episodes will likely be required. Although there is no specific limit to how much fat can be injected in one session, there will be a relative limit according to each patient’s specific situation and the area which is being injected. For example, if there is only a thin pocket for injection, then fat injection must be reduced accordingly to enable the grafts to take. Larger volumes can be injected into larger, well-vascularized areas such as autologous breast reconstruction tissue. Injection volumes can often range between 40 and 200 cc per breast. For example, Losken et al reviewed 107 patients receiving fat grafting for secondary breast reconstruction revision1 and found that an average volume of 40 cc was injected. Weichman et al reviewed 228 patients with free flap reconstruction with fat grafting and found that the average volume was 148 cc per breast.2 A proportion of injected fat is likely to resorb leaving somewhere between 50 and 100% of the injected fat within the breast in the longer term. Therefore, fat transfer is indicated in small to medium volume deficiencies and can be used in larger ones if there is adequate donor site availability and multiple procedures are acceptable to the surgeon and patient. Popular donor sites include the abdomen, flanks, thighs, and buttocks and are patient specific. After abdominal based breast reconstruction, it may be wise to harvest fat with caution centrally and keep the more lateral and the flanks, but there is no absolute contraindication to using the abdomen as a donor site.1–3
In this case, the patient would almost certainly have had bilateral breast ptosis and macromastia prior to mastectomy and reconstruction, and this is now displayed as a unilateral ptosis and oversized breast on the unoperated side. The reconstructive process provides the opportunity to address these preexisting features of the breast and provide breast cancer patients with uplifted and better shaped breasts than perhaps they began with. The first question to consider is what the patients’ preferences are for their breasts. Sometimes patients will prefer to try to match their existing breast, other times they will prefer to match the newly reconstructed one. In this case, the patient has expressed a desire for volume and shape symmetry. A contralateral breast reduction would be the preferred choice as this will address the volume difference and the ptosis the patient displays. This should be performed prior to nipple reconstruction on the transverse rectus abdominis myocutaneous (TRAM) side so that nipple position can be optimized to match the native breast. Breast reduction is the most commonly performed symmetry procedure for autologous reconstruction.1,2 Liposuction may be useful where there is a volume difference between the breasts without a skin difference or ptosis. It is also useful for making subtle adjustments to breast shape. Mastopexy is commonly performed to the contralateral side following autologous or implant-based breast reconstruction and is indicated where there is ptosis without volume differences. Breast augmentation is sometimes used to balance breast asymmetry post reconstruction and perhaps is useful in select small autologous breast reconstruction cases. However, adding a prosthetic to an autologous reconstruction does go against the main principles of autologous reconstruction in that it is intended to create a permanent and natural breast that is unlikely to require long-term alteration. If there is a significant size difference between the breasts and the shape is otherwise good, then an implant may be considered. When implant-based techniques are used, a differential implant on the nonoperated side may be helpful to improve shape and symmetry for some patients. Fat transfer in this case would help address the volume difference but would not address the ptosis. This can be effective for use in TRAM flaps to increase volume or correct specific contour or volume irregularities such as can occur in the upper pole.
The inframammary fold (IMF) is the inferior defining border of the breast footprint and is generally described as being at the level of the fifth or sixth rib, extending from midline to the anterior axillary line.1 The IMF can become effaced during mastectomy or during breast reconstruction, particularly delayed reconstruction. If it is damaged during mastectomy, it is probably best repaired at the time with a suture-based technique as delayed reconstruction can be more difficult to achieve satisfactorily. Reconstruction of the IMF can generally be grouped into three categories: 1. Flap-based reconstruction 2. Suture-based reconstruction 3. Template-based reconstruction Many of these methods are reported either without patient data or only have data reported in the index publication, and there is no single most successful procedure. The Ryan procedure is a local tissue arrangement/ flap approach that involves utilization of a lower thoracic advancement flap to create a neo-IMF.2 A number of external devices have been described for use in the IMF repair but none are specifically designed devices. They include bending an endotracheal tube stylet to the shape of the contralateral IMF and creating a paper template of the hemi-abdomen and IMF and transposing this to the opposite side.3–6