Anatomic Misadventures in Mastectomy and Pearls for Reconstructive Repair

Purpose

 Immediate breast reconstruction rates continue to increase.  Regardless of whether the reconstruction is implant or autologous based, successful results take a well coordinated effort between the oncologic and reconstructive surgeon.  While elimination of breast cancer is the ultimate goal, great emphasis is placed on one's final appearance.  Although the plastic surgeon is charged with task of replacing what is removed, much of the groundwork is determined during the mastectomy.  From incision locations and flap thickness to conserving boundaries of the breast, the reconstruction process actually begins at the start of the oncologic operation.  Frequently, many of these decisions do not include the reconstructive surgeon and can lead to very difficult reconstructive scenarios.   We present several pearls to guide a successful breast reconstruction when faced with unfavorable conditions.

Methods

Over a twenty year career, the senior author (JDF) has worked with numerous oncologic surgeons for both autologous and implant based breast reconstruction.  While the majority of mastectomies have produced straightforward reconstructive efforts, others create obstacles that must be addressed to avoid poor outcomes.  We identified several factors that greatly influence reconstructive efforts:            1. Non-ideal biopsy or mastectomy incision patterns   2. Thin flaps and flap necrosis 3. Anatomic boundary distortions 4. Symmastia 5. Tenuous vascularity to the nipple areolar complex.

We then set out to create a set of pearls to help salvage these difficult circumstances in hopes of producing the best possible outcome.    

Discussion

Foremost, open and interactive communication with the breast surgeon will help circumnavigate many of these potential problems.  Markings for planned incisions and outlining breast borders can be made in the presence of the oncologic surgeon and discussed.  One or multiple breast boundaries may be violated and can be reestablished using sutures and/or acellular dermal matrix.  Symmastia, an especially difficult complication to fix, can be corrected using a combination of pectoral cavity sutures and external sutures with dental cotton rolls.  Nipple areolar viability can be difficult to assess intra-operatively and is best treated conservatively by observation for several weeks.  These are but a few of the many concepts discussed. 

Conclusion

Breast reconstruction is a collaborative effort between the oncologic and reconstructive surgeon. Appearance and complications are often attributed to and dealt with by the plastic surgeon, despite initial factors that are often out of one's control.  It is important to recognize potential pitfalls at the time of reconstruction, and have a plan to avoid significant aesthetic shortcomings and dissatisfied patients.