Reconstructive breast surgery (mammaplasty or mastoplasty) is defined as a series of surgical procedures that is designed to restore the normal appearance of the breast after surgery, disease, accidental injury, or trauma. Breast reconstruction is distinguished from purely cosmetic procedures by the presence of a medical condition, e.g., breast cancer or trauma, which leads to the need for breast reconstruction.
The most common indication for reconstructive breast surgery is a prior mastectomy; in fact, benefits for reconstructive breast surgery in these patients are a mandated benefit in many states.
In contrast, cosmetic breast surgery is defined as surgery designed to alter or enhance the appearance of a breast that has not undergone surgery, accidental injury, or trauma. Reduction mammaplasty is a common example of cosmetic breast surgery, but surgery to alter the appearance of a congenital abnormality of the breasts, such as tubular breasts, would also be considered cosmetic in nature.
There is a broadening array of surgical approaches to breast reconstruction. The most common is insertion of a breast implant, either a silicone gel-filled or saline-filled prosthesis. The implant is either inserted immediately at the time of mastectomy or sometime afterward in conjunction with the previous use of a tissue expander.
For some patients, reconstructive mammaplasty is accomplished in several staged procedures requiring two or three operations. Multiple techniques including tissue expanders, breast implants, regional or distant autologous tissue transfers/flaps, and/or reconstruction of the nipple-areolar complex (and nipple tattooing if applicable) may be required. The following is a listing, with definitions, of breast “flap” reconstructive procedures:
- Latissimus dorsi muscle flap utilizes donor tissue from the patient’s back that can be employed for reconstruction without significant loss of function. The latissimus flap can be moved into the breast defect, still attached to its blood supply under the arm pit (axilla). The latissimus flap is usually used to recruit soft-tissue coverage over an underlying breast implant. There are instances where enough volume can be recruited to reconstruct small breast without the placement of a breast implant;
- The abdominal flap used for breast reconstruction includes the TRAM (transverse rectus abdominis myocutaneous) flap, in which a portion of the abdomen tissue, including the skin, fat tissues, minor muscles, and connective tissues, is taken from the patient’s abdomen and transplanted onto the breast site once the breast cancer has been surgically removed;
- A DIEP (deep inferior epigastric perforators) flap is a type of breast reconstruction, in which abdominal muscle blood vessels, skin, and fat tissues are removed from the abdomen and transferred to the chest to reconstruct a breast without the sacrifice of any abdominal muscles OR
- The superficial inferior epigastric artery (SIEA) flap differs from the DIEP flap by utilizing tissue from the lower abdomen and takes a smaller section of skin and fat tissues to create the new breast. The blood vessels required for this flap come from the fatty tissue.
Nipple areola reconstruction or nipple tattooing may also be considered reconstructive breast surgery.
Since the purpose of reconstructive breast surgery is to restore the normal appearance of the breast, on some occasions, procedures are performed on the contralateral, normal breast to achieve symmetry. These procedures fall into the category of reconstructive breast surgery only when performed in conjunction with a contralateral mastectomy for cancer with associated reconstruction. Except for medically necessary reduction mammaplasty, these procedures are considered cosmetic in other circumstances. Contralateral breast surgery, the modification of the opposite, unaffected breast, may include the following services:
- Reduction mammaplasty, a reconstruction of the breast to decrease in volume by excision of tissue;
- Mastopexy (with or without breast implants) or breast lift, a reconstruction performed to correct ptosis or drooping and sagging of the breast;
- Prophylactic mastectomy, not a procedure, per se; it is the rationale for the appropriateness to remove breast tissue in the absence of malignant disease and is also known as preventive mastectomy. It is typically bilateral, but may be performed unilaterally in a patient who has previously undergone a mastectomy in the opposite breast for an invasive cancer and is at risk for developing cancer in the remaining breast; OR
- A combination of these procedures.
Frequently, additional surgical procedures are required to achieve the optimal final reconstructive results. These include excision of redundant tissue, repositioning of the implant, release of internal scar tissue, creation of inframammary fold, scar revision, and other tissue rearrangement.
The operative plan and specific techniques for breast reconstruction and contralateral breast surgery must be tailored to fit the patient's specific situation. This would include evaluating the terms of the cancer/pathology and the need for further treatment. Immediate reconstruction has the advantages of a shortened mastectomy incision, avoidance of mastectomy deformity, as well as multiple hospitalizations, multiple anesthesia, and postoperative courses. Delayed breast reconstruction following a mastectomy may be necessary when postoperative chemo- or radiation therapy is required. Reconstructive surgery may be performed immediately at the time of the initial surgery (mastectomy) or delayed for months or years.
The breast cancer management team includes, but is not limited to, the general, plastic or oncologic surgeon, radiologist, mammographer, radiation oncologist, medical oncologist, pathologist, breast-imaging specialist, nurses and nurse clinician, and medical social worker.