Breast Reconstruction Techniques

Foundations & Timing - Recon Ready?

• Goals: Restore mound, symmetry, NAC; improve QoL, body image.
• Timing:
  • Immediate (IBR): With mastectomy.
    • Pros: 1 surgery, better aesthetics, psych benefit.
    • Cons: May delay adjuvant; path may alter plan.
  • Delayed (DBR): After adjuvant therapy.
    • Pros: No adjuvant delay; patient adjusts.
    • Cons: Multiple surgeries; less ideal aesthetics.
• Key Factors:
  • Oncological safety.
  • Patient choice, readiness.
  • Adjuvant therapy (esp. Radiotherapy/RT).
  • Comorbidities (smoking, DM, obesity ↑risk).
  • Breast: size, ptosis, skin.

⭐ PMRT (Post-Mastectomy Radiotherapy) strongly influences reconstruction timing & technique selection. oka

Autologous Options - Flap Fantastic

• Uses patient's own tissue (skin, fat, ± muscle); offers natural feel & long-term results.
• Flap Types:
  • Pedicled Flap: Tissue remains attached to its original blood supply & is tunnelled to the chest.
  • Free Flap: Tissue is detached, transferred to the chest & blood vessels reconnected (microsurgery).
• Common Abdominal Flaps:
  • TRAM (Transverse Rectus Abdominis Myocutaneous) Flap:
    • Pedicled (pTRAM) or Free (fTRAM).
    • Blood Supply: Superior Epigastric Artery (pTRAM) or Deep Inferior Epigastric Artery/Vein (fTRAM).
    • Risk: Abdominal wall weakness, hernia, potential partial/total flap loss.
  • DIEP (Deep Inferior Epigastric Perforator) Flap:
    • Muscle-sparing (rectus abdominis muscle preserved).
    • Blood Supply: Perforators from Deep Inferior Epigastric Artery.
    • Advantage: ↓ abdominal morbidity compared to TRAM.
• Latissimus Dorsi (LD) Flap:
  • From the back; often combined with an implant for volume.
  • Blood Supply: Thoracodorsal artery.
  • Donor Site Issues: Seroma, back weakness, visible scar.
• Other Options: SGAP/IGAP (gluteal perforator flaps), TUG (transverse upper gracilis) flap.

⭐ The DIEP flap is generally preferred over the TRAM flap for abdominal-based free flap breast reconstruction due to significantly lower risk of abdominal wall weakness and hernia.

Implant-Based & Combined - Implant Power

• Core: Silicone/saline implants for mound. Simpler, less donor morbidity vs. autologous.
• Approaches:
  • Staged: Tissue Expander (TE) → Permanent Implant. Most common.
    • TE: Submuscular/prepectoral. Gradual inflation.
  • Direct-to-Implant (DTI): Single stage. Good tissue quality needed.
• Combined (Implant + Autologous/ADM):
  • LD Flap + Implant: For poor tissue/prior radiation. Latissimus Dorsi (LD) provides coverage.
  • Acellular Dermal Matrix (ADM)/Mesh: Supports implant, controls pocket, aims for ↓ capsular contracture.
    • 📌 ADM: Assists Durable Mound.
• Key Risks: Capsular contracture, infection, rupture, malposition. Radiotherapy ↑ complications.

⭐ Prepectoral implant placement with ADM is gaining popularity, offering potentially less pain and faster recovery compared to submuscular placement.

Complications & Finishing Touches - Trouble & Trim

• General: Hematoma, seroma, infection, skin/flap necrosis, chronic pain.
• Implant-Specific:
  • Capsular contracture (Baker I-IV); most common.
  • Rupture (Saline: deflation; Silicone: MRI for intracapsular).
  • Malposition, extrusion, rippling.
  • ⚠️ BIA-ALCL (Breast Implant-Associated Anaplastic Large Cell Lymphoma) with textured implants.
• Autologous Flap-Specific:
  • Partial/total flap loss (vascular compromise).
  • Fat necrosis (calcification on mammo, mimics recurrence).
  • Donor site: hernia (esp. TRAM), seroma, weakness, pain.
• Finishing Touches (Aesthetics & Symmetry):
  • Contralateral symmetrization (mastopexy, reduction, augmentation).
  • Lipomodelling (fat grafting) for volume/contour defects.
  • Nipple-Areola Complex (NAC) Reconstruction (typically 3-6 months post-mound):
    • Local flaps (e.g., C-V, skate, star flap).
    • Grafts for areola (full-thickness from groin/contralateral NAC).
    • Medical tattooing (micropigmentation).
  • Scar management (silicone, massage, steroids).

⭐ Fat necrosis in autologous flaps can present as firm masses, oil cysts, or suspicious calcifications on mammography, potentially mimicking cancer recurrence and requiring biopsy for confirmation.

High‑Yield Points - ⚡ Biggest Takeaways

• Autologous flaps (TRAM, DIEP, LD) offer natural results but have donor site issues; implants risk capsular contracture.
• DIEP flap spares rectus muscle, unlike TRAM, reducing abdominal weakness.
• LD flap is reliable, often needs an implant for volume; main risk is donor site seroma.
• Immediate reconstruction is common; delayed may be chosen post-radiotherapy.
• Radiotherapy increases complications for all reconstruction types, especially implants.
• NAC reconstruction (local flaps, tattooing) is the final step for completeness.