Leading article Breast reconstruction after mastectomy Z. Rayter and S. Wilson Departments of Breast and Plastic Surgery, Southmead Hospital, Bristol BS10 5NB, UK (e-mail: zenon.rayter@nbt.nhs.uk) Published online 27 July 2016 in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.10257 Despite the widespread use of breast conservation, mastectomy may still be required in up to 40 per cent of patients for widespread disease, multicentricity, large tumour size in relation to breast size and patient choice 1 . Bilateral mastectomy is the only surgical option for patients with a BRCA1/2 or other genetic mutation undergoing risk-reducing surgery. Although a variety of techniques may be used to reconstruct the breast, the timing, relative indications for specifc approaches and contraindi- cations are far from clear, with a lack of high-quality evidence to support some practices. Breast reconstruction may be offered as an immediate or delayed procedure. The advantages of per- forming immediate reconstruction are that the nipple can be spared (if appro- priate) and the breast skin envelope preserved to enable the reconstruction to be matched with the normal side. Despite this, subsequent correction of asymmetry on the contralateral side is often required. The ideal candidate for immediate reconstruction is a patient who is psychologically well prepared for the surgery, has had time to discuss recon- structive options, and is a non-smoker and not obese, as both factors increase complication rates markedly. Diabetes should be considered a relative con- traindication if associated with other co-morbidity such as hypertension. Although controversial, the sur- geon needs to be confdent that postmastectomy radiotherapy will not be required. This causes cap- sular contracture in implant-based reconstructions and tissue atrophy in autologous reconstructions. As the indications for radiotherapy have increased over the past 5 years, this has become an important considera- tion. Patients with ductal carcinoma in situ, low-volume multicentric disease and node negativity are ideal, and the latter can be identifed with high accu- racy by sentinel node biopsy before defnitive surgery. Patients with infammatory breast cancers (1 per cent), those with locally advanced disease requiring excision of as much skin as possible or those who will need postmastectomy radio- therapy are usually unsuitable for immediate reconstruction. If a patient wishes to have delayed reconstruction, one option is a stage-delayed strategy, whereby a temporary expander is placed under the chest wall muscles at the time of the mastectomy. This creates a breast mound and allows patient the time required to make a choice of the method of delayed reconstruction. The simplest method of breast reconstruction is implant-based. In the past, this was achieved by insert- ing a temporary expander and then replacing this with an appropriately sized permanent silicone implant some months later. Insuffcient lower- pole volume or ptosis can necessitate contralateral mastopexy or reduc- tion mammoplasty. Because of this, a variety of acellular dermal matrices (ADMs) have been introduced as well as synthetic slings to hold the implant in place. ADMs are collagen frameworks derived from chemically denatured human or animal (porcine, bovine or equine) skin to decrease antigenicity 2 . These can be used as a sling stitched between the pectoralis muscle and the inframammary fold, or can be completely wrapped around the implant, then fxed to the chest wall without dissecting the chest wall mus- cles. It is claimed that the presence of an ADM makes breast reconstruction more resistant to capsular contracture caused by radiotherapy. Although some evidence for this is beginning to emerge 3,4 , there are no reliable long-term data. Long-term outcome, quality of life and cost-effectiveness of these expensive meshes should be addressed urgently with good quality randomized trials. More complicated methods of breast reconstruction involve the creation of pedicled or free faps. The most widely used pedicled fap is the latissimus dorsi fap, which may be supplemented with an implant in patients with a low BMI, or, if using an extended harvest- ing approach, may be entirely autol- ogous. This is a very robust fap, and has a failure rate of less than 0.5 per cent, with excellent cosmetic results and high satisfaction rates in appro- priately selected patients 5 , especially those whose BMI is too high for con- sideration of the use of a free fap. The main drawbacks are donor-site sero- mas, although these can be reduced by quilting 6 , and donor-site pain. The pedicled transverse rectus abdominis muscle (TRAM fap) includes skin, fat, blood vessels and rectus muscle, and is tunnelled from the abdomen to the chest. The high risks of abdominal bulge and/or hernia have made this fap less popular, and it is contraindicated in women who have a scar in the upper abdomen from © 2016 BJS Society Ltd BJS 2016; 103: 1577–1578 Published by John Wiley & Sons Ltd Downloaded from https://academic.oup.com/bjs/article/103/12/1577/6146892 by guest on 11 October 2022