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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