PLASTIC SURGERY
Other breast reconstruction advances soon followed. Implants
were found to be more reliable when placed in the subpectoral
position to help camouflage the upper pole wrinkles of the im-
plant and support the lower implant pole to resist sagging. Tissue
expanders could be temporarily used to grow the muscle pocket
and skin, to ultimately place appropriate sized implants at a later
stage in a short same-day operation. This staging process aided
the vascularity and survival of the thin mastectomy skin through
reducing pressure on the overlying skin.
Over the last decade, several breast reconstruction techniques
have been advanced or revisited including the DIEP flap, fat graft-
ing, direct to implant, and prepectoral implant placement, and on-
coplastic flaps. However, implants are still the most popular meth-
od for breast cancer reconstruction, specifically with smooth tex-
tured implants to minimize the possible risk for anaplastic large
cell lymphoma (ALCL), which has been associated with long term
indwelling textured implants.
The DIEP flap, which involves a modification of the TRAM
flap, was described to minimize donor abdominal weakness and
hernia risk. It is similar to the TRAM in lower abdominal skin ter-
ritory but allows for sparing more muscle by carving limited blood
supply out of the muscle to supply the flap. Having less blood sup-
ply, the DIEP has more risk for flap fat necrosis. The DIEP flap,
like the TRAM flap, is most suitable for bilateral reconstructions
to preserve abdominal muscle strength and reduce hernia or bulge
risk. The DIEP flap involves microsurgical connection of blood
vessels from the abdomen to the internal mammary vessels be-
neath the ribs. As such, this more complex operation requires lon-
ger operative time and hospital stay.
Fat grafting involves the harvest by liposuction of fat from
unwanted areas. This fat is then prepared by a variety of studied
mechanisms for injection into specific areas needing more vol-
ume. Fat graft injection of the breast was initially popularized for
cosmetic breast enlargement by Roger Khouri. Breast fat grafting
remained controversial because of the oncogenic potential of pre-
cursor stem cells in the lipoaspirate and the creation of masses
in the breast obscuring mammogram accuracy. After studies de-
lineated differences between benign fat graft and malignant sus-
cipious mammographic findings fat grafting became utilized in
breast cancer reconstruction. However, fat grafting has only been
embraced by the American Society of Plastic Surgeons (ASPS) for
mastectomy defects and not lumpectomy defects because of the
unknown oncogenic potential of fat into remaining breast cancer
areas. Fat grafting is mainly used now for contour corrections and
as an adjunct to other primary reconstructions.
Acellular dermal matrix (ADM) and other skin substitutes
have recently been developed and become popular to allow for
placement and maintenance of the implant in the subpectoral po-
sition. Using the skin substitute can camouflage the implant edges
and assist with pocket control. From this development the direct
to implant technique of reconstruction was re-initiated. Direct to
implant immediate breast reconstruction can be considered for bi-
lateral breast reconstruction when small implants are desired un-
der thick mastectomy flaps in non-smoking patients. Loss of skin
with skin sparing mastectomy (SSM) reduces the ability for ideal
match in unilateral reconstruction with this direct to implant, as
the tissue expanding stage is skipped with this approach.
Also derived from the development of skin substitutes, implant
placement in the prepectoral position has been reintroduced, in
an effort to avoid animation of the implant with pectoral muscle
strain and to preserve the muscle. With the prepectoral technique,
the implant is temporarily maintained from sagging and camou-
flaged by the skin substitute. The prepectoral implant reconstruc-
tion can be considered for patients with thick mastectomy skin
and small implants that won’t weigh and sag much over time.
Reduction mammoplasty techniques, initially introduced for
breast reconstruction of lumpectomies for benign conditions,
have finally been accepted as oncologically safe for cancer defects
and are now called Oncoplastic flaps. Oncoplastic reconstruction
is used specifically for lumpectomy reconstruction when patients
have an abundance of breast tissue and/or need reduction on the
other side. These oncoplastic flaps are complex designs based on
plastic surgery principles used in various breast reduction pedicles
to restore the breast shape and preserve nipple vascularity in relo-
cating the nipple to a more desirable position. These patients need
to heal fast, as they will require postoperative radiotherapy, and
therefore cannot be smokers.
Recent media reports have once again created hysteria impli-
cating implants to cause tumors, ALCL. What these reports failed
to highlight is that ALCL is very rare and also a less aggressive
variety of cancer, that has been associated with textured breast
implants over an extended period. The predicted risk of ALCL
development in a patient with textured surface breast implants is
1:30,000. The majority of implants placed the last several decades
have been smooth surface implants. Patients that experience dra-
matic enlargement of one breast or new fluid collection around
the breast are evaluated for this rare condition by mammogram,
ultrasound and then fluid aspirate for cytology.
Through the Brown Cancer Center and other tertiary specific
referrals, our University of Louisville team of plastic surgeons has
contributed to and embraced this evolution of various breast can-
cer reconstruction developments. We provide a thorough evalua-
tion and individualized approach to each and every one of our pa-
tients with the ability to perform cutting-edge care and procedures
based on current research to remain at the forefront of our field.
Dr. Wilhelmi practices as Chief of Plastic Surgery at the University of
Louisville, where he also serves as Leonard J. Weiner, MD, Professor
and Plastic Surgery Residency Program Director. In addition, he prac-
tices as a Breast Plastic Reconstructive Surgeon at the Brown Cancer
Center.
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