Following a mastectomy breast reconstruction can be performed at the same time or as a delayed procedure. Reconstruction may need to be delayed to allow effective local therapies such as radiotherapy to the chest wall. Other factors to be taken into consideration when deciding on breast reconstruction include the following:
· Patient preference.
· The risk of recurrence. If there is a high risk of recurrence reconstruction may be delayed.
· Previous irradiation does not rule out breast reconstruction but may affect the choice of surgical techniques.
Reconstruction of the breast involves either the use of a breast prosthesis or an autologous myocutaneous flap:
· Breast prostheses such as silicone gel implants are usually inserted under the muscles of the chest wall. The skin may need to be gradually stretched first using a tissue expander. Expansion to form a cavity slightly larger than the implant allows the reconstructed breast to hang naturally (ptosis). Previously irradiated skin may be too rigid to allow stretching. Complications include capsular contracture, infection and pain.
· Myocutaneous flap reconstruction involves taking a piece of muscle with its overlying skin to create a breast mound. A pedicle flap retains its original blood supply and is tunnelled under skin to the breast. A free flap requires its blood vessels to be surgically reanastomosed such as a latissimus dorsi flap. A TRAM (transverse rectus abdominus myocutaneous) flap is an ellipsoid piece of skin, fat and muscle taken from across the whole width of the abdomen. It may be used as a pedicle or free flap. Complications of myocutaneous flaps include necrosis of the flap and scarring of the donor site.
Nipple reconstruction may be achieved by shaping of the reconstructed breast tissue and tattooing to achieve the correct colour. Nipple prostheses offer an alternative to further surgical treatment.
Sufficient counselling on the advantages and disadvantages, the problems and complications of the techniques must be given to all patients.