MODERN SITUATION IN BREAST RECONSTRUCTION AFTER MASTECTOMY.pdf INTRODUCTION Breast cancer is the second most common cancer in the world and, by far, the most frequent cancer among women with an estimated 1.67 millionnew cancer cases diagnosed in 2012 (25% of allcancers). The lifetime risk of being diagnosed with breast cancer for women of all races is about 16%. This means one out of every 8 women will developbreast cancer at some point of their lives [1]. Breast reconstruction has become an appropriate option for women diagnosed with breast cancer, and in recent years there have been an increasenumber of patients choosing breast reconstructionafter mastectomy. Several studies of women whoundergo mastectomy find correlations between УДК 618.19-089.87-089.844:618.19-77 doi 10.17223/1814147/60/05 aesthetic outcome and the level of depression and anxiety [2-7]. The myriad of reconstructive procedures available and the rapidly evolving nature of the field make it a particularly challenging area in plastic surgery. Maintaining competence in breastreconstruction requires not only expertise in technical innovations but also knowledge of the medical developments that influence patient care. Thebreast reconstructive surgeon is required to apply this breadth of expertise in a varying context of individual patient circumstances. It allows better aesthetic- functional outcomes and consequently an improvement of the psychological aspects of patients with breast cancer [8-9]. Recent refinements in autogenous tissue techniques, improvements in prosthetic technologies, Вопросы реконструктивной и пластической хирургии № 2 (61) июнь’2017 46 Jaume Masia, Elena Rodriguez-Bauza and development of novel tissue substitutes haveinduced noticeable advances in breast reconstruction. The approach to breast reconstruction will beadapted to attain an appropriate balance betweenminimizing the risk of recurrence and providing thebest aesthetic outcomes. Many authors have reported that women whoundergo breast reconstruction have less mentaldistress about losing a breast and better cosmeticresults, self body image, and overall quality of life [10-11]. The purpose of this article is to present our management of the different surgical techniques forbreast reconstruction as well as the analysis of theirinvolvement in the quality of life of our patients. BREAST RECONSTRUCTION Breast reconstruction can be classified into two major categories based on the timing of surgery(immediate or delayed) and on the material used to reconstruct the breast. Reconstruction can be performed through implants (alloplastic reconstruction), through body tissue (reconstruction with autologous tissue) or reconstruction using mixedtechniques (implant placement + autologous tissue). All these techniques have a series of indications that will be analysed next. The techniques that have gained more popularity in recent years are those that use the patient's own tissue to recreate the breast, since it offers results very similar to those of a natural breast. The flap used most frequently for autologous breast reconstruction is the deep inferior epigastric perforator flap. However, in some patient reconstruction using breast implants is more appropriate. The surgical modality, choice of immediate versus delayed reconstruction, and approach for thecontra lateral breast all must be established preoperatively. Patient concerns and expectations mustbe explored in depth. Patient incentives include thedesire for wholeness and body image restoration and avoidance of external prosthesis use. Care mustbe taken to avoid expectations that are too high by clearly describing potential complications and expected results [9]. Autologous tissue reconstruction remains the technique associated with the highest patient satisfaction and represents the gold standard for recreation of the breast mound. The surgeon specializing in this field requires experience and knowledge ofall available techniques to guide the patient to the technique best suited to their particular diagnosis, values, and long-term goals [12]. Timing for breast reconstruction - Immediate reconstruction Immediate reconstructions permit skin-sparing mastectomies and reduce the total number of pro cedures and associated costs needed for the final outcome. Skin-sparing mastectomies markedly improve appearance by limiting incisions to the periareolar region and avoiding a skin color mismatch. The avoidance of an interim period of mastectomy deformity can have psychological benefits. Paradoxically, women who have delayed reconstructions experience greater increases in qualityoflife measures and satisfaction with breast appearance than immediate reconstruction patients [13]. Differences in preoperative mental health states andexpectations likely account for this phenomenon. Skin-sparing mastectomy and immediate reconstruction has been found to provide superior cosmetic results and comparable quality of life to breast conservation therapy [14]. Skin-sparing and modifiedradical mastectomies result in similar rates of mastectomy skin flap necrosis and local recurrence [9]. Most women with breast cancer are candidates for immediate breast reconstruction and should be considered in all prophylactic mastectomies. Immediate breast reconstruction may not be appropriate for women with very advanced or rapidly growing tumors where surgical margins may be involved, those with multiple or serious medical problems, and those who are psychologically unprepared for reconstruction. Smokers are at increased risk of complications and should quit smoking as far in advance of surgery (6 weeks) if possible. - Delayed reconstruction: Delayed reconstruction is possible any time after cancer treatment is complete. There are neitherage limits nor a finite length of time after mastectomy (or lumpectomy) when reconstruction would not be considered. Delayed breast reconstructionshould be considered if tumor clearance is uncertain and in patients with extensive Stage III orStage IV disease in whom immediate postoperative chemotherapy and radiation is expected. In delayed reconstructions, as opposed to immediate surgery, missing breast skin usually must beexpanded by an implant or replaced using a flap. Additional scars may be visible when compared to immediate reconstruction (where the breast skin and often the nipple is preserved), and a secondary procedure will be required to reconstruct a nipple and areola (as opposed to nipple-sparing procedures). Surgical procedures Implant breast reconstruction - Two-staged implant breast reconstruction Traditional implant breast reconstruction involves two stages in which shapeless skin remainingafter a mastectomy is slowly expanded over manymonths using a tissue expander. A permanent implant is placed in a second operation, and the nipple and areola are reconstructed as a third procedure in delayed reconstruction cases. № 2 (61) июнь’2017 Вопросы реконструктивной и пластической хирургии Пластическая хирургия 47 In the first stage, an expander is placed deep to the pectoralis muscle and fascia. Care should be taken to ensure good muscle coverage directly under the incision to prevent implant exposure in theevent of mastectomy skin flap necrosis. The expander is then inflated using biweekly injections until a threshold overexpansion of approximately30 percent is reached. In the second stage, which is usually performed within 3-6 months after, the inflated expander is replaced with a permanent saline or silicone implant. In general, ideal candidates for tissue expansionare women who have not undergone irradiationwhen delayed reconstruction is performed. - Single-staged implant breast reconstruction Single-staged implant breast reconstruction is indicated in immediate cases in those women who are not likely to receive radiation therapy and who, due to the type of tumour, undergo a nipplesparing or skin-sparing mastectomy. The procedure should be considered in womenwith a small-breast size who have not undergoneirradiation and who have excess chest wall skin after mastectomy, and also in women with a bigbreast size using a nipple-sparing mastectomyfollowing mastopexy or reduction pattern [15]. This type of surgery must be performed very carefully, since the skin flap of the mastectomy has poorirrigation, and if the sub dermal plexus is not properlypreserved, it could cause skin flap suffering, with the subsequent extrusion of the prosthesis [16]. Intraoperative fluorescence imaging also can help to determine whether adequate perfusion is retained to the breast skin envelope for immediate insertion of the permanent breast implant [17]. Adjunct techniques for implant-based reconstruction after mastectomy include the use of biological (a cellular dermal matrix)and syntheticmeshes that can be placed in the inferior pole of the breast or completely covering the implant. Theseadjunct tecnhiques have increased considerably the indication of implant breast reconstruction, allowing the reconstruction with implants in a singletime. However, mesh placement is not without complications and its indications in reconstructivesurgery are limited [18-19]. One-stage implant reconstruction is less costlythan a two stage option and tends to better maintain the ptotic shape of the breast, which results in amore natural-appearing reconstructed breast. The advantages of implant breast reconstruction include reduced operating times and surgicalmorbidity. The lack of a donor site facilitates the procedure from both a technical and a clinical point of view. Disadvantages include implantrelated problems such as capsular contracture, deflation, and migration. Implant reconstructions generally have a less natural feel and appearance compared with autologous tissue. The typical needfor a two phases surgical approach might also beviewed as a drawback. Reconstruction with implants may be a good option in patients who have not received radiotherapy, in thin patients with very little autologoustissue to recreate a new breast, or in patients who, due to their medical conditions or their own preferences, require a short and simpler intervention. Onthe other hand, although the surgery is shorter, the patient may require a longer period in the reconstruction process, especially if two-staged reconstruction is required. As the implants are foreignelements to the human body, they may need a replacement in the future, so it presents less stabilityand longevity compared to reconstruction withautologous tissue. In addition, it may be difficult to achieve a natural form with respect to the contra lateralbreast, so this type of intervention is usually recommended in patients with small breasts, who donot tend to fall over time. Also is a good indication in bilateral cases, so it is easier to achieve adequate symmetry (Figure 1). ab c Figure 1. 47-year-old female who underwentrisk-reducing bilateral mastectomy and immediate reconstruction with breast implant (anatomical breast implant 285gr). The patient refused the preservation of the nipple areola complex: a - shows the preoperative pictures; b - shows the postoperative result after 6 months; c - shows the postoperative result after nipple areola reconstruction at one year postoperative Вопросы реконструктивной и пластической хирургии № 2 (61) июнь’2017 48 Jaume Masia, Elena Rodriguez-Bauza In summary, reconstruction with implants hasbeen frequently supported in patients with minimaldonor sites or in those who wish to minimize the deformity of donor sites. Although the result isgenerally less natural compared with autologoustissue reconstruction, it can provide reasonable results in suitable selected patients. Autologous breast reconstruction Autologous reconstruction, on average, achieves the best cosmetic match to the native, mature breast. The reconstructed breast has ptosisthat is determined by the native skin envelope, and a soft feel provided by the transplanted fat. Autologous tissues are more resistant to infection and notsubject to capsular contracture. Finally, after theinitial reconstruction and necessary revisions, autologous reconstructions require less late interventions and will change in size with patient weight gain and loss. Overall, this is the preferred reconstructive procedure in women who are appropriatecandidates. The tissue of the abdomen, by its characteristics, is considered as the ideal donor site. It gives us, in most cases, enough volume to recreate a new breast, and the inherent characteristics of the skin and fat from abdominal area (colour, thicknessand consistency) make it the most breast-like tissue[20-21]. - Deep inferior epigastric perforator flap(DIEP flap) The DIEP flap has become the “gold-standard” technique of breast reconstruction, since it usesonly skin and fat the lower abdomen, without altering the muscular function of the area. Dissection of the DIEP flap can be quite challenging technically, requiring surgical skills to perform successful flap dissection, but with experienced surgeon is a completely safe technique and offers good results. Dissection of the perforating vessels of the deep inferior epigastric artery out of the rectus muscleyields significantly longer vessel lengths, therebyfacilitating insetting at the recipient site. Indeed, compared with free TRAM flaps, lower rates of abdominal wall herniation, pain, and bulge formationand shorter hospital stays have been shown. TheDIEP flap has been shown to have less abdominal wall morbidity and lower fat necrosis rates, shorterhospital stays, and complete flap loss rates similarto those of pedicled TRAM flaps. As a consequence of shorter hospital stays, DIEP flap reconstructionshave been found to be more cost effective than TRAM flaps [22]. Performing DIEP flaps in overweight and obesepatients may not place the flap at greater risk because proportionately larger abdominal wall perforators are present in these patients. The use of computed tomographic angiography can serve as a “road map” to optimally position the flap overlyingthe perforating blood vessels and to hasten the selection and dissection of the perforating bloodvessels. In many cases an aesthetic benefit can be offered to the abdomen. The excision of abdominal tissue is performed following the patterns of abdominal aesthetic dermolipectomy, trying to achieve the best result. The abdominal scar is designed to lie low on the torso and is usually completely hidden in undergarments or a swim suit. Closure of the abdominal donor site creates the effect of a “tummy tuck” (Figure 2). a b Figure 2. 58 year-old female who underwent delayed right breast reconstruction with DIEP flap and breast contra lateral symmetrization: a - shows preoperative markings; b - postoperative result at 9 months The double-DIEP flap is especially useful forthin patients who need additional volume to reconstruct the breast or for patients who have had radiation therapy who need a large amount of skin replacement. № 2 (61) июнь’2017 Вопросы реконструктивной и пластической хирургии Пластическая хирургия 49 All these characteristics lead us to define DIEP the technique of choice for breast reconstruction. In our experience, applying this approach clearly and concisely, most patients opt for reconstruction with DIEP. We don’t perform in thosepatients who have an alteration of the abdominal wall or lack of excess abdominal tissue. Relative contraindications are active smoking, obese patients (BMI > 30) and age over 70 years. - Superficial inferior epigastric artery flap(SIEA) The free SIEA flap carries the same abdominaltissue as the previously described flap. The vascularpedicle can be dissected superficially and inferiorlydown to its origin off of the femoral vessels withoutdamaging the abdominal wall. The flap has negligible abdominal wall morbidity beyond what wouldaccompany a typical abdominoplasty. It has the advantage of being the least invasive technique and that less morbidity causes the patient to not have to open the abdominal fascia tolook for the vessels of the deep system. However, the vessels tend to be small or absent and are only suitable for use in 30 percent of patients. In addition, the flap has a more limited vascular territory and is only appropriate for womenwith A to B cup breast sizes [23]. Routine dissection of the vessels is reasonable, as they may allowturbo charging (vascular augmentation) of compromised DIEP flaps. - Other Free Perforator Flaps If the abdomen does not provide an adequate source of tissue for breast reconstruction, the gluteal tissue (SGAP flap / IGAP flap), thigh tissue (TMG flap), lumbar flap (LAP flap ), the posterioraspect of the thigh (PAP flap) or even flap from thecontra lateral breast (breast-sharing flap) could be performed. These flaps are not commonly used, and not all centres may offer these techniques. These flaps are usually used when the patient wishes to reconstruct with autologous tissue and it is not possible to perform abdominal tissue reconstruction or tissue from the dorsal region because they are very thin orthey have had previous surgery that contraindicatestheir use. The superior gluteal artery perforator flap carries fat and skin from the upper buttocks region. The donor site can result in buttock asymmetry, which occasionally requires a contra lateral balancing operation. The flap is nonetheless an improvement over the superiorgluteal free flap because the pedicle is longer and muscle is not sacrificed. The inferior gluteal artery perforator flap issimilar to the superior gluteal artery perforator flapbut uses tissue from the lower part of the buttock, resulting in better donor-site contour and a moreconcealed scar (Figure 3). Figure 3. 1 year postoperative result after bilateral breast reconstruction with bilateral SGAP flap - Pedicled Latissimus Dorsi Flap The latissimus dorsi musculocutaneous flapispedicled on the consistently reliable and robustthoracodorsal axis and is therefore a good optionfor patients with risk factors such as tobacco use, diabetes, or excessive body weight. The flap is generally used in combination with an implant reconstruction. Skin and muscle from the latissimus flapcan be used to replace radiation-damaged skin. Unlike pure implant reconstructions, latissimusflaps allow the lower lateral pole of the implant tobe covered with a thick layer of autologoustissue, resulting in a better aesthetic outcome. The flapcan also be used without implants. Overweight patients with small breasts are reasonable candidates for completely autologous latissimus reconstruction. However, donor-site asymmetryc an be striking and may necessitate a balancing liposuction procedure. Disinserting the muscle from its humeral insertion increases flap mobility, decreases breastmovement with contraction, and makes the axillamore accessible for detecting nodal disease onphysical examination. However, this maneuverdoes increase the risk of pedicle avulsion injury. Shortcomings include the need for intraoperative repositioning/redraping and implant-relatedcomplications. Seroma rates of 47 to 96 percent are reported [24]. Donor-site asymmetry can be significant if large volumes of tissue are harvested inoverweight patients. Although not common, somewomen may have weakness in the back, shoulder or Вопросы реконструктивной и пластической хирургии № 2 (61) июнь’2017 50 Jaume Masia, Elena Rodriguez-Bauza arm after this surgery by using the broad dorsalmuscle for reconstruction [25]. - Thoracodorsal Artery Perforator Flap(TDAP) The pedicled thoracodorsal artery perforatorflap uses the same vascular supply and skin territoryas the latissimus flap. Perforating vessels arising onor just medial to the superolateral border of thelatissimus flap are dissected proximally through thelatissimus muscle. Care must be taken when separating the vessels from the thoracodorsalnerve topreserve latissimus muscle function. Wide variability in perforator anatomy is themain reason why this flap has not gained widespread popularity. The thoracodorsal artery perforator flap and the similarly conceived intercostalartery perforator flap is a potential solution for largequadrantectomy defects. Also, it has been described total breast reconstruction with TDAP flap [26]. - Fat grafting Autologous fat grafting allows to achieve good results in the partial reconstructions of breast or tocomplement other reconstructive techniques (especially those that use patient's own tissue like theDIEP). The increasing use of autologous fat grafting also has contributed to enhanced aesthetic outcomes using implant-based breast reconstruction. Surgeons have begun to perform fat grafting as apreliminary step after radiation therapy and before the exchange for the permanent implant. The objective is to decrease subsequent wound healing problems and implant dehiscence during the second stage (Exchange for the permanent implant). Future research will need to focus on the best timing at whichto apply fat grafting to a reconstructed breast. DISCUSSION There is evidence showing that breast reconstruction is a safe option for the majority of womenundergoing mastectomy for breast cancer and thatit does not have an adverse effect on rates of recurrence [27]. Clinical guidelines around the world recommend that the option of breast reconstruction be offered to suitable women choosing or requiring mastectomy, with acknowledgement thatthis may need to be carefully sequenced with other cancer treatments and that in some situations delayed rather than immediate reconstruction may be preferable. Despite these recommendations, ahighly variable proportion of women actually undergo breast reconstruction. Reported rates ofbreast reconstruction in population studies rangefrom 5 to 30% [27]. A wide variety of factors including patient age, comorbidities, insurance status, planned adjuvant therapy, geographical and local access issues as well as surgeon attitudes/ expertise and patient choice have been proposed as explanations for generally low rates of reconstruction. Breast reconstruction means a primordial steptowards normality, not only restoring a lost organ, but also helps to regain lost femininity and helps to forget the terrible fight that has been carried outagainst the disease. It does not interfere either in the treatment or in the control of the patients, andmore and more oncologists recommend breast reconstruction [28-29]. Ideally, all plastic surgeons involved in breast reconstruction should have considerable knowledge and experience, if not all, in most reconstructive techniques. From implant breast reconstruction and latissimus dorsi flap reconstruction to themore sophisticated techniques of perforator flaps (DIEP, SIEA, SGAP...). Immediate reconstruction is currently considered the standard of care in this surgical intervention. However, the optimal timing for breast reconstruction after mastectomy remains a topic of controversy, especially in the setting of radiationtherapy. Techniques also include a more focuseduse of flaps only in the setting of radiation therapywith increasing use of new perforator-basedautologous tissue flap options [30-32]. Autologous tissue technique should, in fact, be used as a standard in breast reconstruction, except in cases where it is contraindicated, that may bemedical conditions, women with few autologous tissues to recreate the new breast, or patient preferences. Patient expectations play a major role in postoperative satisfaction, and realistic outcomes mustbe discussed from the outset. Patients deemed to have inadequate preparatory information beforeembarking on breast reconstruction have been shown to have a higher rate of decisional regret anddissatisfaction. A thorough preoperative evaluationof the patient’s expectations and suitability for a particular reconstruction is therefore essential. CONCLUSION Breast reconstruction is an elective procedurethat aims to improve the quality of life of patientsaffected by breast cancer. Breast reconstruction should be valued as more than rebuilding a breastin the context of a mastectomy. It is an essentialstep in the recovery of the physical and psychic sequels produced by the treatment of breast cancer inwomen, and should be analysed individually. Therefore, the only way to achieve good breast reconstruction begins with an adequate study of thedisease and especially of the woman who suffersfrom it. № 2 (61) июнь’2017 Вопросы реконструктивной и пластической хирургии Пластическая хирургия 51 In this way the choice of the most appropriate surgical techniques and the ability to communicate technique should be done in a consensual way be-in a clear and honest way to the patient. tween the patient and the plastic surgeon. In order to Breast reconstruction should not be consi- achieve a truly adequate choice of technique, it is es-dered a posterior step of breast cancer treatsential that the plastic surgeon have the sensitivity toment, it should be considered an essential part understand the patient, the essential experience of all for an integral treatment.

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