Table 2 The indications, contraindications, disadvantages, and advantages of breast reconstruction
From: MR imaging of the reconstructed breast: What the radiologist needs to know
Implant-based reconstrucions | TRAM (Pedicle/free flap) | Lattisimus flap | Perforator flap surgery DIEP/SIEP/SGAP/IGAP/TUG | |
|---|---|---|---|---|
Indications | Patients with inadequate in-situ donor tissue | Radical mastectomy defect with large tissue requirement | Thin habitus | Autogenous tissue reconstruction is preferred to avoid sacrifice of the muscle tissues traditionally associated with these techniques |
Patients who cannot tolerate increased length of surgery required for pedicle reconstruction | History of radiation to the chest wall | Previous abdominal operations (including abdominoplasty) | Unsatisfactory or previously failed implant reconstruction | |
Shorter recovery time | Large opposite breast (difficult to match with an implant) | Preferred dorsal donor site | As a replacement for implants in cases of severe capsular contracture, which is more often found in patients who have required radiation therapy | |
Moderate to severe obesity | Small opposite breast (difficult to match with an implant) | Failed implant or TRAM reconstruction | Autogeneous tissue reconstruction is one option available for restoring form in those with deformities from volume loss due to prior lumpectomy, radiation, or subcutaneous mastectomy | |
Patients who are undergoing bilateral reconstruction but are otherwise candidates for transverse rectus abdominis muscle (TRAM) reconstruction may be considered for implant-expander reconstruction to avoid the morbidity of using both rectus muscles | Previous failure of implant reconstruction | Patients desiring future pregnancy | Congenital breast absence or underdevelopment (Poland syndrome) | |
Excess lower abdominal tissue and patient desires abdominoplasty | ||||
Contra-indications | Insufficient skin and/or subcutaneous tissue to cover the implant | Inadequate excess abdominal tissue | Posterior thoracotomy | Prior procedure that may have injured the vessels that perforate the rectus sheath (i.e., abdominoplasty) |
Relative contraindication: significant ptosis of the contralateral breast as implants are unable to achieve a natural ptotic appearance; in these patients, autologous tissue reconstruction or a contralateral symmetry procedure is indicated | Certain abdominal incisions from previous surgical operations may have inadvertently caused a disruption in the necessary blood supply to the TRAM flap | Implants not desired | Routine abdominal operations such as cesarean delivery, hysterectomy, appendectomy, cholecystectomy, and laparoscopic procedures do not usually pose a problem | |
Patients with a history of smoking, hypertension, obesity, chronic obstructive airways disease, previous abdominal surgery, and diabetes mellitus are considered high risk (may choose pedicle flap technique) | Severe cardiac disease | Smoking is often problematic. An absolute minimum of 3 weeks of smoking cessation is recommended before surgery | ||
Severe pulmonary disease | ||||
Advantages | Minimally invasive | No implant | More natural tissue and natural result, but usually still needs/requires implant | No implant |
Shorter operation, shorter recovery | Very natural looking | Decreases risk associated with implant and radiation[16] | Very natural looking | |
Minimal scarring to rest of the body | Ages with patient | Longer initial surgery | Ages with patient | |
No muscle trauma | Less fat necrosis-better blood supply | Minimal abdominal weakness and abdominal hernia | ||
Longer operation | ||||
Disadvantages | Overall complication rate is 10.5% with implant-based reconstruction. Most common complications are infection (4 %), followed by malposition (3.5%), rupture (1.7%), extrusion (0.6%), and capsular contracture (0.6%) [17] | Complete removal of rectus, decreased with placement of mesh path [18] | Lose muscle function-initial shoulder weakness 15-20% | Technically difficult operation |
Altered tension on thoracolumbar fascia- back pain | Synergistic muscle compensation (teres major, subscapularis, pectoralis major) | Risks associated with microsurgery | ||
Decreased abdominal strength, especially pronounced with bilateral procedure |