Breast Reconstruction

With the increasing number of cases and younger onset age of female breast cancer, breast reconstruction is no longer seen as an optional procedure after mastectomy, but rather as an essential step toward the mental and physical health breast cancer patients through the reconstruction of physique and confidence. It is also an indicator of healthcare progress for a country. The desire and need of patients for breast reconstruction need to be recognized, and the ideology of physicians behind surgeries also needs to keep up with times. They should change the traditionally narrow view of reconstruction of a “single” breast and proportionally transform it to the reconstruction of a “pair” of breasts or even an “entire” person. Breast reconstruction should no longer be the “last resort” but rather an “esthetic” augmentation mammoplasty for increasing both esthetics and function.

Currently, there are two types of breast reconstructions.

• Immediate Reconstruction
  As soon as the breast is removed, the plastic surgeon reconstructs the breast. This approach requires coordination between the breast cancer and plastic surgeons and thus can be performed only in hospitals. The surgery mainly utilizes an autologous flap transplant to the breast tissue defect. In other words, skin and fat tissues with complete vascular pedicle from other parts of the body (e.g., lower abdomen, thighs, or back) are transplanted to areas of mastectomy. The blood vessels of the flap should be anastomosed to on-site chest vessels to maintain the circulation of transplant tissues under microsurgery. The last procedure is then completed with the sculpting and adjustment of breast shape and symmetry.The advantages of this surgery are that it involves a single operation for both mastectomy and reconstruction and that autologous tissues have the same feel and texture as real breasts. However, symmetry is harder to achieve with unilateral reconstruction, and the overall operating time is very long (6–7 h on average). Patients are required to stay in the intensive care unit (ICU) for the observation of the circulation of the flap because once the connected blood vessels become clogged, it could lead to flap necrosis. Furthermore, many patients feel unhappy with the additional scar from the donor site of the flap and the “patchy” scars over the reconstruction site. Thus, this procedure is not popular locally.

• Delayed Reconstruction
  Patients can consider breast reconstruction 1 year after mastectomy or after being confirmed to be cancer free during follow-up visits. These procedures mostly involve “esthetic” augmentation mammoplasty with breast implants. The goal of reconstruction is to not just restore one side of the breasts but rather an integrated evaluation of both sizes to accomplish the esthetics of symmetry and balance.The surgeon will decide to perform one- or two-step reconstruction, depending on skin elasticity, thickness, and amount of tissue remaining. Common prostheses to use in this surgery are saline and silicone implants. With different stages of tissue extension and sizes or types of implant selection, the purpose “ipsilateral reconstruction and contralateral augmentation” can be achieved. This surgery is advantageous in that an original incision from mastectomy can be used without leaving patchy scars on the breasts or additional scar from the donor site of flap reconstruction; different sizes and types of implants can be used to achieve optimal symmetry with more flexibility than the unilateral flap transplant used in immediate reconstruction. In addition, reconstructions with breast implants are highly reversible; thus, they can be removed any time once deemed unnecessary. As for the procedure’s shortcomings, it has a longer recovery period averaging 6 months to a year for completing the whole course of reconstruction and has risks associated with implants such as foreign body reaction or capsular contracture. Patients must regularly undergo postoperative massage to achieve the expected result.

Apart from patients undergoing mastectomy due to breast cancer, many other patients with breast tissue injury due to accidents may also require breast reconstruction; e.g., those with pathological changes due to silicone injection, breast trauma, burn, etc. Because these patients have different etiologies of breast diseases, method of surgery, range of excision, and characteristics of skin, a thorough surgical plan is made depending on individual conditions to ensure that the entire reconstruction process can be completed step-by-step. Because breast reconstruction is a long journey, both patients and surgeons need to invest more time and effort to obtain the desired results.

Tissue expender and simulative saline sizer are used in breast reconstruction surgeries in order to accurately measure the difference in the two breast and adjusted to reach symmetry.