Primary breast reconstruction

Authors: Mia Demant, MD, Mia Wangsmo Steffensen, MD

Definition

Breast reconstruction is performed during the same procedure as mastectomy, therefore also termed ‘immediate breast reconstruction’ (IBR). Skin-sparing mastectomy needs immediate reconstruction in order not to lose the skin envelope that will retract and shrink to the level of the thoracic wall if unreconstructed.

Indications

• Breast cancer 
• Prophylaxis due to increased risk of breast cancer (family history and/or genetic predisposition), since neither adjuvant chemotherapy nor radiotherapy will be required 

Methods

Prosthetic reconstruction (with implants and expanders)

This is the most commonly used method for breast reconstruction, although there is an increasing tendency to choose reconstruction with the patient’s tissue (1).

Placement 

• Subpectoral (covers the implant/expander from thin mastectomy flaps), and usually also below the anterior part of musculus serratus anterior and the upper part of the musculus rectus abdominis fascia
• In recent years, it has become more common to form a pocket for the implant by lifting the pectoralis major muscle and ‘extending’ it by sewing a plate of biological acellular dermal matrices, which serves as a template for the patient’s connective tissue cells, that subsequently grow into the mesh – this often allows immediate insertion of the permanent implant (2)

Direct to implant reconstruction

Indications

• Small to medium-sized breasts, or planned contralateral reduction for symmetry
• Sufficient skin envelope
• If the patient wants to avoid additional donor site wound 
• If the patient does not have any adequate flap donor site (e.g. lean patient, pre-existing scars, or medical conditions/comorbidities) 

Contraindications

• Postoperative radiation therapy planned (risk of capsular contracture and implant extrusion)
• Lack of sufficient skin envelope

Advantages (3)

• Single staged – no additional procedures necessary (lower surgery- and recovery-related costs)
• No donor site morbidity
• A better aesthetic outcome (preserving most of the original skin)
• Reduced surgery and recovery time

Disadvantages

• Inability to expand the existing pocket, not able to fill large mastectomy defects with adequate volume 
• Risk of implant complications (hematoma, infection, capsular contracture, and rupture)

Expander-based reconstruction

Stages of expansion

1. The expander is placed during the primary surgery
2. The tissue is then expanded weekly with serial saline injections over approximately 4-6 weeks – overexpansion is often preferred to create skin envelope laxity 
3. The final volume is maintained for a shorter period to allow capsule maturation before exchange to the permanent implant 3-4 months after primary surgery

Advantages

• No donor site morbidity
• A better esthetic outcome (preserving most of the original skin)

Disadvantages

• Frequent out-patient visits when gradually filling the expander
• An additional procedure (expander removal for permanent implant or flap)
• A relatively high rate of complications (infection, capsular contracture, and skin perforation) (4)

Indications

• Sufficient skin envelope
• Postoperative radiation therapy planned – the filled expander will help protect the pocket from contracture and induce laxity in the expansion process
• If the patient wants to avoid additional donor site wound 

Contraindications

• Insufficient skin envelope secondary to surgical procedure