As systemic, surgical, and radiation treatments continue to evolve and to improve survival outcomes for patients with breast cancer, new techniques for partial and total breast reconstruction also have emerged. Some of these techniques improve functional or cosmetic outcomes; others expand breast cancer treatment options by making satisfactory reconstruction available.
As part of a multidisciplinary care team, plastic surgeons at The University of Texas MD Anderson Cancer Center have employed several new techniques for partial or total breast reconstruction in response to the evolving nature of breast cancer treatment. These techniques include the use of nontraditional donor sites and new harvest methods for vascularized tissue transfer flaps and improvements to implant-based reconstruction. “As plastic surgeons,” said Jesse Selber, M.D., an associate professor in the Department of Plastic Surgery, “we have to be able to adapt different techniques to fit in with the overall breast cancer treatment.”
Reconstruction after lumpectomy
Breast-conserving therapy, in which patients undergo lumpectomy followed by radiation therapy, has been shown in several large studies to be oncologically equivalent to mastectomy for many types of breast tumors; as a result, an increasing number of patients are considering lumpectomy. “Relative to the number of mastectomies, we’ve seen an increase in the number of breast-conserving surgeries with immediate reconstruction,” said Mark Schaverien, M.D., an assistant professor in the Department of Plastic Surgery.
Reconstruction as part of breast-conserving surgery most commonly involves breast tissue rearrangement using modified breast reduction or mastopexy techniques, which do not restore the breast to its former volume and therefore usually necessitate symmetrizing reduction surgery on the contralateral breast. These techniques are indicated for patients with large, ptotic breasts in whom bilateral breast reduction is viewed as a positive outcome or reduction is necessary to facilitate radiation therapy.
For patients with small or moderate breasts, minimal ptosis, and a large tumor-to-breast volume ratio, pedicled perforator soft tissue flaps are sometimes the best option for partial breast reconstruction. The lumpectomy and reconstruction are performed in a single outpatient operation, and symmetrizing surgery to the contralateral breast is not required.
The latissimus dorsi muscle and thoracodorsal artery perforator flaps are well established for partial breast reconstruction; however, more advanced flaps are indicated for some defects. For instance, lateral breast defects can be repaired using pedicled flaps from the lateral chest wall, such as the lateral intercostal artery or lateral thoracic artery perforator flaps. And inferior or medial breast defects can be repaired using flaps from the anterior chest, such as the anterior intercostal artery or medial intercostal artery perforator flaps. The scars from these advanced flaps lie in the inframammary or lateral breast folds and are well concealed by a bra or swimsuit strap.
“These flaps are commonly used outside of the United States and are a valuable addition to the armamentarium of plastic surgeons performing oncoplastic breast reconstruction,” said Dr. Schaverien, who was among the first surgeons in the United States to introduce advanced pedicled chest wall perforator flaps for immediate partial breast reconstruction. “These chest wall flaps do not involve or include muscle, so there is very low donor site morbidity. Most importantly, the latissimus dorsi muscle and its blood supply are preserved in case they are needed for total breast reconstruction in the future.”
After partial breast reconstruction using breast tissue or a perforator flap, radiation therapy sometimes causes contracture or scar tissue in the reconstructed breast. “Deformities that develop during radiation therapy can be repaired by an injection of fat, or what we call autologous fat grafting,” said Matthew Hanasono, M.D., a professor in the Department of Plastic Surgery who pioneered the technique (see “New Fat Grafting Technique Improves Aesthetic Outcomes Following Head and Neck Reconstructive Surgery,” OncoLog, April 2014).
Reconstruction after mastectomy
For patients who require mastectomy, total breast reconstruction may be performed using implants, vascularized tissue flaps, or both. Dr. Selber said that new techniques for both implant- and flap-based breast reconstruction are improving aesthetic and functional outcomes for patients at MD Anderson.
Implant-based total reconstruction
Implant-based reconstruction, the most common type of total breast reconstruction, was introduced in the 1970s and is traditionally performed by detaching the pectoral muscle, placing a tissue expander underneath, and suturing the muscle back together to hold the implant in place; the tissue expander is later replaced by the permanent implant.
The first major innovation in implant-based reconstruction came in 2005 with the use of acellular dermal matrix to hold the tissue expander (and later the implant) in place. Typically, the top of the implant is held in place by the pectoral muscle, and the bottom is supported by acellular dermal matrix so that the implant can sit lower for a more natural appearance. But when acellular dermal matrix is used in this manner, the pectoral muscle is still dissected and reattached, which causes temporary pain and creates an animation deformity such that the breasts move when the pectoral muscle moves.
Several surgeons, including Dr. Selber, decided to experiment with a different way to use acellular dermal matrix. “About a year and a half ago, some of us in the global plastic surgery community started to think that if we were using acellular dermal matrix in this fashion to sort of create an internal bra for the implant, then perhaps we didn’t need to use the pectoral muscle at all,” he said.
The resulting technique, prepectoral implant-based breast reconstruction, may be the next evolutionary step in implant-based breast reconstruction, according to Dr. Selber. In such a reconstruction, the tissue expander/implant is placed on the pectoral muscle, and the acellular dermal matrix supports the implant from beneath and on its front surface, holding it securely against the chest wall to provide stability.
Dr. Selber now uses the prepectoral technique for almost all his implant-based breast reconstructions. “Patients are very happy with the results,” he said. He added that, compared with the traditional method of covering the implant with the pectoral muscle, “The pain and recovery time are dramatically reduced, and the early aesthetic results are better. Also, it’s a faster and simpler technique. There are a lot of advantages to both the patient and the surgeon. I would say this technique is revolutionizing implant-based breast reconstruction.”
Flap-based total reconstruction
Other recent advances in total breast reconstruction have been in the use of tissue flaps. Some of these advances reduce scarring; others increase options for donor sites or improve function.
A major functional impairment for many breast cancer survivors is lymphedema of the upper extremity, a condition caused by removal or damage to the limb’s draining lymph nodes. To relieve this condition, MD Anderson surgeons often perform a vascularized lymph node transfer, in which lymphatics are moved and anastomosed along with a free deep inferior epigastric perforator (DIEP) flap for simultaneous total breast reconstruction (see Advances in Surgical Management of Lymphedema, OncoLog, April 2017).
When a patient’s anatomy is not suited for a DIEP, transverse rectus abdominis myocutaneous, or other free abdominal flap for total breast reconstruction, plastic surgeons have other options. Profunda artery perforator or transverse upper gracilis flaps harvested from the upper thigh and gluteal artery perforator flaps harvested from the buttock result in well-concealed scars with minimal donor site morbidity. Along with these flaps, advanced techniques such as stacked or bipedicled flap configurations can be used to increase the tissue volume available for breast reconstruction. “These free flaps and techniques are expanding the options for patients who have insufficient abdominal tissue for breast reconstruction or have previously had multiple abdominal surgeries,” Dr. Schaverien said.
A more common donor site for tissue flaps for total breast reconstruction is the latissimus dorsi muscle, which can be used with or without the overlying skin to cover an implant. For patients who do not need a skin flap, Dr. Selber devised a minimally invasive technique for harvesting the latissimus dorsi muscle (see “Robotic Surgery Makes Tissue Harvest for Breast Reconstruction Less Invasive,” OncoLog, May 2013).
In the minimally invasive procedure, the surgeon uses robotic instruments to separate the latissimus dorsi muscle from the surrounding tissue. The pedicled flap is then transferred under the skin to the breast. “If you don’t need to transfer skin, you don’t need to make a skin incision,” Dr. Selber said.
The robotic procedure has a specific place in MD Anderson’s algorithm for “delayed immediate” breast reconstruction, which is when a patient gets a tissue expander in the same operation as her mastectomy and then undergoes radiation therapy followed by final reconstruction. During the final reconstruction, the expander may be replaced by a permanent implant; in such a case, a vascularized tissue flap is often needed to cover the implant.
Dr. Selber has taught the robotic tissue harvest technique to several colleagues and trainees at MD Anderson, some of whom have since moved to other institutions. However, the procedure is routinely done only at MD Anderson.
Drs. Selber, Hanasono, and Schaverien emphasized the importance of plastic surgeons’ involvement with the multidisciplinary care team. The type of oncological surgery and the need for radiation therapy affect the options for reconstructive surgery. Conversely, the type of reconstructive surgery (e.g., prepectoral versus standard placement of tissue expanders) can affect radiation therapy planning.
“There are many options in breast cancer treatment and breast reconstruction,” Dr. Selber said. “So it’s important to have deep and ongoing communication between the medical, surgical, and radiation oncologists and plastic surgeons—not just at the initiation of therapy but throughout therapy because the patient’s condition and the treatment needed evolve throughout the course of care.”
For more information, contact Dr. Matthew Hanasono at 713-794-1247 or firstname.lastname@example.org, Dr. Mark Schaverien at 713-794-1247 or email@example.com, or Dr. Jesse Selber at 713-794-1247 or firstname.lastname@example.org.
Visible Light Spectroscopy Improves Postoperative Tissue Flap Monitoring
A recent study by MD Anderson surgeons showed that a new postoperative tissue monitoring technique, visible light spectroscopy, offers greater sensitivity and specificity in detecting thrombosis in vascularized free tissue transfer flaps than does the standard of care.
Vascularized free flaps are commonly used in reconstructive surgery after oncological resection of breast and other cancers, but nationwide up to 9% of free flaps fail because of thrombosis. If thrombosis is detected early, compromised flaps can usually be salvaged. However, the standard techniques for flap monitoring, which are visual inspection and Doppler ultrasonography, have significant limitations. Both techniques are performed intermittently rather than continuously, visual inspection is done by staff with varying experience levels, and Doppler ultrasonography detects only arterial—not venous—compromise.
Visible light spectroscopy is a noninvasive technique that continuously monitors hemoglobin saturation of tissue at the capillary level and total hemoglobin concentration. Decreased hemoglobin saturation indicates arterial compromise, and increased total hemoglobin concentration indicates venous compromise.
In the recent study, Dr. Selber and his colleagues used both visible light spectroscopy and standard postoperative monitoring in 68 patients with 81 flaps. In three patients, flap compromise was detected by visible light spectroscopy but not by visual inspection or Doppler ultrasonography. All three patients returned to surgery, and the compromised flaps were salvaged.
“Visible light spectroscopy is a technology we’ve introduced here recently that can be used with any free tissue transfer that has a skin pad on the outside,” Dr. Selber said. “It’s the next generation of flap monitoring that goes beyond human observation.”
The study’s report was published in Plastic and Reconstructive Surgery (Mericli AF, et al. Plast Reconstr Surg. 2017;140:604–613).