Breast Disease

Bilateral breast reconstruction may be indicated in women with bilateral cancers, those with unilateral cancer and a high risk of developing a contralateral cancer, or in women who choose bilateral prophylactic mastectomy. Numerous options for reconstruction are available, including TRAM flaps, latissimus dorsi flaps, and saline or silicone gel-filled implants. The discoveries of the BRCA1 and BRCA2 gene mutations and their implications for breast cancer risk have led to renewed interest in prophylactic mastectomy. Recent studies have confirmed that prophylactic mastectomy is effective in reducing breast cancer risk, but the decision to proceed with prophylactic mastectomy must be made on a case-by-case basis.

Post-mastectomy breast reconstruction with prostheses can be performed immediately at the time of mastectomy or delayed for several months or years. It falls into three main categories namely implant-only, expander-implant and expandable implant reconstruction. Sometimes it is combined with the latissimus dorsi myocutaneous flap. Logistically prosthetic reconstruction can be single-stage (with implant-only or expandable implants) or two-stage (traditional expander-implant technique). Over the last decade a wide variety of prostheses has become available which materially vary in shape, surface and consistency.

Prosthetic breast reconstruction provides satisfactory results in properly selected patients and has the advantages of simplicity, shorter operating time, hospital stay and recuperation. Additionally there are no extra scars or distant donor site morbidity. It is, however, more prone to additional unplanned revisional surgical procedures than autogenous tissue reconstruction. In general two-stage reconstruction gives more predictable results as it gives the surgeon the opportunity to adjust the reconstruction at the planned 2nd stage, while in practice, single stage reconstruction may be more prone to unplanned revisional surgery. The best results are obtained in patients with small minimally ptotic breasts while those with larger and/ or more ptotic breasts often require a contralateral balancing procedure to achieve symmetry.

This paper outlines the surgical options and the prosthetic range available at present.

A perforator flap consists of skin and fat harvested from a donor site nourished by myocutaneous perforators while sparing the donor muscle for function and strength. This flap type has revolutionized microvascular free tissue transfer and the technique has been successfully applied to well-established donor sites for autologous breast reconstruction namely the lower abdomen, upper and lower buttock, the upper back, and the lateral thigh. Although these flaps are technically more demanding than conventional myocutaneous free flaps, their minimal impact on the donor site muscle function significantly reduces local morbidity, postoperative pain and hospital stay.

Perforator flap breast reconstruction has an increased operating time because of the meticulous dissection of the perforators, the possible anatomical variation in their location and, once these are located, the difficulty in selecting suitable perforator(s) to base the flap on. Although it has been suggested that perforator flaps may have a higher incidence of fat necrosis and partial flap loss than conventional free myocutaneous flaps, this has not been borne out by clinical results. There is, however, a learning curve and careful patient selection is important.

The role of perforator flap technique in breast reconstruction is evolving. While its indications are similar to those of free TRAM and gluteal flaps, it is clearly a better alternative to these. The choice of perforator flap depends on where the patient has the most abundant donor tissue and the surgeon's experience. These flaps may in the future become the standard of care in free flap breast reconstruction.

The human body is one of near perfect bilateral anatomical symmetry. Often we all easily compare and contrast differences between one hand and the other, both in their appearance as well as their function. This also is true with breast reconstruction. While one breast is reconstructed, the opposite unaffected breast may be changed to match the reconstructed side. The goals of any symmetry procedure are to perfectly match bilateral breast size, shape, projection, and nipple-areolar position. The unaffected breast may be enlarged, reduced, or lifted to recreate the near perfect breast symmetry. We will discuss the indications and techniques of breast symmetry procedures after breast reconstruction.

Similar to other surgical disciples, plastic surgery has recently benefited from the introduction and application of endoscopic technologies. The creation and shaping of the reconstructed breast can now be performed via shorter, more remote incisions, which can be re-located to areas of improved cosmesis and improved wound healing. This less invasive approach to breast reconstruction (and the associated symmetry procedures) provides the opportunity for less tissue trauma and enhanced visualization. Such benefits may translate into quicker patient recovery and decreased operative morbidity.

Failure of a breast reconstruction is a devastating event for both the patient and the physician alike. By the very nature of reconstructive surgery, much is invested by the patient and the surgeon to accomplish a successful breast reconstruction. It is sometimes difficult to think rationally about the fate of a reconstruction once failure looms on the horizon and the decision-making process can become clouded. The reconstructive surgeon must play an active role in the decision-making process regarding salvage of a reconstructed breast versus abandonment of a failed reconstruction. Although many reconstructive options are available, the patient's prognosis, need for adjuvant therapy, physiologic and mental state, and desires must all be factored into any decision regarding the ultimate fate of the breast reconstruction.

Women faced with breast cancer may develop musculoskeletal impairments following mastectomy and breast reconstruction. The purpose of this review is to highlight physical therapy considerations with these surgeries. Our experience at a large medical center is described, and suggested exercise guidelines are provided. Close communication between physician and physical therapist is emphasized. Physical therapists facilitate patient education, skillfully evaluate and treat musculoskeletal dysfunctions, and provide individualized patient exercise prescriptions. Physical therapists also serve as valuable members of a multidisciplinary breast cancer team.

This chapter reviews psycho-social issues relevant to the management of breast reconstruction patients, with suggestions for assessment and intervention to support maximal response to surgical treatment. The author is a clinical psychologist as well as a breast cancer/reconstructive surgery survivor.