CHAPTER 22 Breast Reconstruction
INDICATIONS FOR BREAST RECONSTRUCTION
I. Total Mastectomy Defect: Breast reconstruction most often follows total mastectomy (i.e., removal of the nipple–areolar complex as well as the complete removal of breast tissue) for the treatment of malignancy or a premalignant condition. Genetic screening for mutations within the BRCA gene loci has led to a dramatic rise in the frequency with which bilateral prophylactic mastectomy is performed. Such procedures are often coupled with bilateral reconstruction.
PREOPERATIVE EVALUATION
I. History: A number of factors influence the choice of a reconstruction technique. A history of radiation therapy or planned postmastectomy radiation therapy significantly influences the timing and choice of a reconstruction approach. Specifically, implant-based techniques are contraindicated in patients who are likely to receive radiation therapy.
II. Current smoking adversely affects wound healing after surgery for breast reconstruction. Patients should be encouraged to stop smoking several weeks before surgery.
III. The presence of diabetes can have an adverse effect on wound healing. Appropriate perioperative management of blood sugar is essential.
IV. Patient age can influence the choice of reconstructive technique. Elderly patients are at slightly higher risk for complications after autologous reconstruction. Conversely, autologous reconstruction is often favored in younger patients.
V. The lower abdomen is the most common source of autologous tissue for breast reconstruction. Patients must, therefore, have sufficient lower abdominal tissue to allow for autologous reconstruction. Very thin patients are often better served by implant-based reconstruction. Although obese patients have sufficient tissue, they are also at greater risk of developing wound complications.
COMPONENTS OF THE PROCEDURE AND APPLIED ANATOMY
Patient Positioning and Preparation
I. The patient is placed supine on the operating room table. The patient should be placed with the hips at the break in the table to facilitate sitting upright.
Skin-Sparing Mastectomy
Mastectomy techniques have a significant effect on the outcome of autologous breast reconstruction. Since 1996, the skin-sparing mastectomy has been increasingly used in conjunction with immediate autologous breast reconstruction. A skin-sparing mastectomy is typically performed with a periareolar incision and is so named because the skin envelope of the breast is kept intact during the procedure (Fig. 22-1). Thus, the reconstructive surgeon must simply replace the volume of the mastectomy specimen with either autologous tissue or an implant. This approach avoids the challenges associated with shaping the breast during traditional delayed reconstruction.
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