Secondary breast reconstruction

Authors: Mia Demant, MD, Mia Steffensen, MD

Definition    

Breast reconstruction is performed as a separate later procedure, also called ‘delayed breast reconstruction’ (DBR). 

Indications

• Patients who are planned for radiation therapy and/or chemotherapy after surgery, hence if reconstruction is performed at the same time, there is an increased risk of complications, which may result in a postponement of the adjuvant treatment
• Patients who have had a reconstruction failure with immediate breast reconstruction
• Patients who accept donor site morbidity, longer operation time, hospitalization, and convalescence

Methods where no radiation therapy has been performed

Expander/implant  

Go to the chapter “Primary breast reconstruction”.

Lipofilling

Definition

Lipofilling (also termed autologous fat grafting) describes the harvesting of a patient’s excess fat using liposuction followed by its reinjection into the tissue to be corrected/augmented. The method dates more than 100 years since Holländer corrected a retracted scar after mastectomy by injecting fat into the scar (2).

Indications

• Correction of post-surgical irregularities (e.g. contour deformities and volume asymmetries together with ‘rippling’ after implant-based reconstruction)
• In selected cases, de novo reconstruction of the breast by lipofilling has shown promising results (the patients need several donor sites since the procedure usually takes four to six stages of fat grafting, each separated by 3 months at least) (3)
• (Fat grafting can sometimes be offered after completion of adjuvant radiotherapy as ‘refinement surgery’) 

Methods

Structural fat injection technique with small aliquots using blunt cannulas in multiple directions and layers. This approach maximizes the fat-to-tissue-contact and thereby the exposition of non-vascularized fat to vascularized host tissue (4). 

Complications

• Fat necrosis
• Oil cysts
• Unfortunately, fat necrosis can be associated with microcalcifications, which may be difficult to distinguish from malignant breast cancer-associated microcalcifications

Methods with concomitant radiation therapy

These methods include reconstruction with the patient’s tissue, either as pedicled flaps or as free flaps (which requires microsurgical techniques).

The Latissimus Dorsi (LD) flap

Definition

A pedicled myocutaneous flap with an overlying skin island (in DBR it is often necessary to include a larger amount of skin). 

The LD flap is frequently combined with an implant, as there is often not enough tissue. 

Advantages

• Consistent anatomy and easy flap harvest
• A rich blood supply makes it a safe flap to use

Disadvantages

• Risk of highly visible scars, contour deformity of the thorax/back
• Risk of animation deformity due to innervation of the LD muscle
• The patient might experience a decreased medial rotation force of the arm, adduction, and extension in the shoulder and the procedure may also affect the postural muscles (1)

The Thoracodorsal Artery Perforator (TAP) flap

Definition

A fasciocutaneous flap supplied by musculocutaneous perforator/perforators from the thoracodorsal vessel axis and/or its vertical branch derivate. Hence, it is a relatively thin and flexible skin paddle.

The Transverse Musculocutaneous Gracilis (TMG) flap

Definition

A musculocutaneous free flap is based on the ascending branch of the medial circumflex femoral artery with two venae comitantes, which come from the profunda femoris vessels (5). The internal mammary vessels are chosen as primary recipient vessels.  

Advantages 

• A robust vascular pedicle and easy harvesting of the flap
• A well-hidden donor site and a concealed scar in a natural skin fold 
• Bilateral reconstruction – and the flap is ideal for immediate bilateral reconstruction, especially after prophylactic mastectomy
• The flap can be harvested using a two-team approach

Disadvantages

• The relative paucity of available skin in the setting of secondary breast reconstruction
• Excessive pubic hair can be problematic in secondary breast reconstruction, and further laser treatment may be indicated

Deep Inferior Epigastric Perforator (DIEP) flap

Definition

A fasciocutaneous free flap based on perforators from the deep inferior epigastric artery that arises from the external iliac artery.

Free abdominal flaps are currently the most frequently used technique for breast reconstruction with the patient’s tissue (11). For more details please visit the “DIEP flap site” in the “Microsurgery” chapter:

DIEP flap procedure