Simultaneous Contralateral Breast Reduction/Mastopexy with Unilateral Breast Reconstruction Using Free DIEP Flaps

Abstract

In the past 60 years, development in medicine has greatly improved early diagnosis, precise staging, and comprehensive treatment of breast cancer, which contributed to the increasing survival rate of patients with breast cancer [1, 2].

15.1 Background

In the past 60 years, development in medicine has greatly improved early diagnosis, precise staging, and comprehensive treatment of breast cancer, which contributed to the increasing survival rate of patients with breast cancer [1, 2].

In addition, technical advancement in breast surgery has remarkably enhanced the safety and effectiveness of sentinel lymph node biopsy, skin sparing radical mastectomy, and immediate breast reconstruction [3, 4].

The development of breast oncoplasty has raised the expectations of patients including extended survival time and tumor recurrence free interval as well as restoration of beautiful appearance and function of the breast [5,6,7,8].

Autologous breast reconstruction was commonly performed at delayed stage in the past, now it is well recognized that immediate reconstruction is better at constructing a natural and beautiful breast [9].

However, patients’ cosmetic expectations frequently come true not simply by reconstructing the affected breast but also adjusting the shape, size, and symmetry of both breasts. Hakyal and Guay [1] reported that the proportion of breast adjustment subsequent to immediate breast reconstruction using autologous tissue (TRAM flap, muscle-sparing TRAM flap, and DIEP flap) for breast cancer was 11.3%.

Successful breast reconstruction they defined was that patients achieved satisfactory reconstructive outcome in only one anesthesia operation, otherwise failure was deemed.

At present, it is recognized that the criterion for successful and satisfactory breast reconstruction is not only to reconstruct a normal breast shape, but also to restore the symmetry of bilateral breasts to the greatest extent, which requires adjusting the contralateral breast such as contralateral breast augmentation, contralateral breast reduction, and contralateral mastopexy [1, 6,7,8, 10]. In Asian female patients, contralateral breast augmentation is the most frequently used breast adjustment [10].

In addition, it is worth noting that the rate of tumor tissue accidentally found in the contralateral breast tissue on pathological examination is 4.6% [11].

15.2 Timing of Operation

Stevenson and Goldstein [8] confirmed that unilateral autologous tissue breast reconstruction concurrent with contralateral breast adjustment was safe and cosmetically satisfactory.

Adjusting the contralateral breast simultaneously with reconstructing the affected breast using autologous tissue may provide with a better outcome [6].

The purpose of breast reconstruction is to reconstruct beautiful, symmetrical, and natural breasts. The most important measurement is the symmetry of bilateral breasts, which requires adjusting the contralateral breast, and often completed at a delayed timing [8, 12]. Delayed adjustment was thought to be better on the ground that the results of the reconstructed breast was time dependent [6].

Further studies have proved that the safety, cosmetic effect and satisfaction of immediate contralateral breast adjustment is as good as that of delayed surgery [10].

In addition, the coincidence of breast cancer can be investigated in dealing with the contralateral mammary glands [11].

At present, there is no final conclusion on when contralateral breast adjustment should be performed after breast reconstruction to achieve satisfactory results [6, 8, 11].

The timing of contralateral breast adjustment is still controversial [1].

Stevenson and Goldstein [8] first made a statistical comparison on the effect of delayed and immediate breast reconstruction with pedicled rectus abdominis flap transfer.

Losken [6] reported the recovery of 1394 patients who underwent contralateral breast adjustment without making a statistical comparison between the effects of immediate and delayed surgery.

Giacalone [7] reported 683 cases of breast reconstruction with autologous tissue and prosthesis to achieve bilateral breast symmetry, yet the timing of operation was not mentioned.

Some scholars evaluated the satisfaction after breast reconstruction using BREAST-Q questionnaire, which presented as a tool to measure the effect of breast reconstruction and contralateral breast adjustment. Their results proved that immediate reconstruction was associated with better effect and satisfaction [13].

Many scholars favor staged surgery [8, 14, 15], which has many advantages, such as shortened operation time, reduced blood loss, lowered possibility of breast asymmetry, and no interference with the implementation of comprehensive treatment.

When the patient’s own conditions meet the requirements, autologous tissue transplantation should be first considered for breast reconstruction [5,6,7,8, 16, 17].

The indications of contralateral breast adjustment depend on the patient’s breast condition, the operator’s technical skills, the patient’s expectations for breast shape, the surgical approach for breast cancer, and reconstruction methods [8, 18].

Indications for contralateral breast adjustment include:

• 1. The patient was not satisfied with contralateral breast ptosis or hypertrophy.

• 2. The volume and shape of the reconstructed breast were not matched with that of the contralateral breast.

• 3. Breast ptosis is graded II or III level and significant vacancy is observed on the superior breast.

The occurrence of contralateral breast cancer can also be investigated in contralateral breast adjustment [11].

15.3 Preoperative Design and Donor Site Preparation

The new inframammary fold (IMF) and the upper margin of the breast as well as the new nipple position on the contralateral breast are marked when the patient is standing. The distance from the nipple to the sternum in Asian women is generally 19–21 cm.

Surgery was underwent by three teams at the same time. One team prepares breast skin envelope and recipient vessels. The second team completes free flap harvest and vascular anastomosis, and the third group performs adjustment of the contralateral breast.

Hidalgo et al. [19, 20] reported the details of contralateral breast surgery including inverted “T” incision and vertical incision, which can be flexibly selected.

The method of mastopexy depends on the degree of breast ptosis. Benelli method is applied for a moderately ptotic breast, an inverted “T” incision and vertical incision are used for the correction of severe breast ptosis.

Breast reduction can be completed by an inverted “T” incision introduced by Hidalgo, where the second to third and fourth to sixth internal thoracic perforating vessels were preserved to provide sufficient blood supply for the nipple areola complex and the upper chest wall skin [21].

Some scholars simultaneously performed immediate breast reconstruction and contralateral breast augmentation endoscopically. The symmetry of bilateral breasts was satisfactory, the appearance was beautiful, and the patient satisfaction was high [10, 22].

Shaping of the reconstructed breast with autologous tissue should be done according to the size and shape of the modified breast on the other side.

Case Study 1: Unilateral Breast Reconstruction with DIEP Flap Plus Contralateral Breast Augmentation with Prothesis: The Internal Thoracic Vessels and Lateral Thoracic Vessels Used as Recipient

The patient was a 51-year-old female, who once received right radical mastectomy for breast cancer plus left mastectomy plus left breast reconstruction with prosthesis. She was given 4 cycles of chemotherapy after operation. After comprehensive treatment, the patient recovered. Subsequently, prosthesis displacement and capsule contracture occurred. She underwent right chest scar resection, right breast reconstruction with free DIEP flap, capsulectomy, and prothesis replacement. Bilateral deep inferior epigastric arteries and veins were end-to-end anastomosed with the proximal and distal ends of the right internal thoracic arteries and veins, respectively. The new prosthesis placed into the left breast was 215 cc in size.

The flap survived completely, bilateral breasts were symmetrical, and the function and appearance recovered satisfactorily. Tumor recurrence was negative on pathological examination (Figs. 15.1, 15.2, 15.3, 15.4, 15.5, 15.6, 15.7, and 15.8).

Fig. 15.1

Preoperative findings and design

Fig. 15.2

Prosthesis replacement was performed on the left breast through the original areola incision, and the skin envelope was prepared after scar resection of the right chest wall. The vessels in the receiving area were lateral thoracic vessels and internal thoracic vessels

Fig. 15.3

Flap cutting process. (a) Exposing the perforating vessels of the left lower abdomen. (b) Opening the anterior sheath and retrogradely separating the perforating vessels toward the posterior sheath. (c) A modified incision was used to expose and separate the deep inferior epigastric vascular pedicle and the adjacent intercostal nerve branches. (d) The left DIEP flap was prepared in rendezvous method

Fig. 15.4

The vascular pedicle of the flap was separated. (a) Preparing a DIEP flap with bilateral vascular pedicles, both of which continued with the medial perforators on each side. (b) The reserved SIEVs on both sides were overfilled. (c) Retrograde extraction of the left vascular pedicle from the intramuscular tunnel. (d) The right vascular pedicle was separated retrogradely till where it was close to the emitting plane

Fig. 15.5

The front and back of the flap

Fig. 15.6

Revascularization mode. (1) Internal mammary vessels; (2) Right deep inferior epigastric vessels; (3) Lateral thoracic vessels; (4) Left deep inferior epigastric vessel

Fig. 15.7

(a) Intraoperative view immediately after reconstruction; (b) 3 months at follow-up

Fig. 15.8

10 months at follow-up after operation

Case Study 2: Unilateral Breast Reconstruction with DIEP Flap After Removal of Displaced Tissue Expander Plus Contralateral Mastopexy

A 31-year-old woman underwent right modified radical mastectomy plus immediate dilator implantation after 6 cycles of neoadjuvant chemotherapy in a local hospital.

Postoperative radiotherapy was given and tissue expansion was continued after radiotherapy.

The expander had been moving upward for 2 years before the patient received capsulectomy, expander removal, and free DIEP flap transplantation for right breast reconstruction plus left mastopexy through double peri-areola incision.

After the scar on the right chest wall and expander were removed, the right internal thoracic artery and its accompanying veins were separated for anastomosis. The size of the designed flap was about 26 cm × 12 cm. A DIEP flap based on bilateral vascular pedicles was prepared.

The right and left deep inferior epigastric artery and vein were anastomosed with the proximal and distal ends of the right internal thoracic artery and vein, respectively.

The left mastopexy was performed using double peri-areola incision. The flaps survived well, bilateral breasts were symmetrical, and the functional feeling of reconstructed breast was satisfactory (Figs. 15.9, 15.10, 15.11, 15.12, 15.13, 15.14, 15.15, 15.16, 15.17, 15.18, 15.19, and 15.20).

Fig. 15.9

Preoperative design

• Markings were made when the patient was standing before operation.

• The plastic incision of the lower abdominal wall is usually used. The harvest range is determined according to the amount of abdominal fat and skin relaxation, which extends upward above or to the level of the umbilicus and downward as low as possible, so that the postoperative scar is hidden.

• In some cases, the perforating vessels lie beyond the umbilical level and adipose tissue accumulates at a higher level of the lower abdomen, resulting in harvesting a flap from a higher level of the lower abdomen. Patients should be informed.

• Expander displacement: where the expander is placed is responsible for the postoperative effect of two-stage prothesis-based reconstruction. Subpectoral expander is commonly displaced by the inferior pectoralis major muscle that has not been interrupted.

• The displacement often occurs with the lower part of tissue expander, frequently resulting in extremely high or low level expander. In immediate breast reconstruction, the expander is often placed behind the pectoralis major muscle. Where the pectoralis major muscle ends inferiorly is higher than the level of the inframammary fold, as a result, the position of the subpectoral expander is often too high.

• If it is a slight asymmetry, we can usually correct it by adjusting the capsule cavity during prosthesis replacement. In cases with significant expander displacement or asymmetrical inframammary folds, we need to surgically adjust the position of the expander as soon as possible. Expander displacement would lead to tissue over-expansion at where expansion is not required. This is commonly seen when the expander shifts upward and dilates the superior chest skin, ending up with thin soft tissue on the upper breast and insufficient expansion on the lower breast. This can be solved by adjusting early the expander position and good long-term outcome can be often accomplished.

• The most important goal of one-stage implantation of expander is to level the inframammary fold close to that of the opposite side.

The asymmetry of bilateral inframammary folds will become obvious during expansion.

In patients with high reconstructed IMF, it can be corrected by removing the lower capsule and separating downward in the process of prosthesis replacement.

If the tissue covering the prosthesis is too thin to be completely removed, capsulotomy can be made in parallel or crisscross pattern.

Prothesis implant follows. The symmetry of the reconstructed IMF and the naturality of the semi-circle shape of the lower breast is determined in upright position.

Fig. 15.10

The expander and the capsule were removed and the internal mammary vessels were prepared

Fig. 15.11

Separating the left deep inferior epigastric perforator and vascular pedicle

Fig. 15.12

Separating the right deep inferior epigastric perforator and vascular pedicle

Fig. 15.13

Separation of right vascular pedicle was completed

Fig. 15.14

The left vascular pedicle was cut off, the flap was connected to the donor area only by the right perforator and vascular pedicle

Fig. 15.15

Clamping the right perforator vascular pedicle, ICG angiography found that the blood supply to the opposite side of the flap was insufficient, and the patient had insufficient abdominal fat. As a result, the whole lower abdominal tissue was needed, requiring bilateral vascular pedicles for blood supply

Fig. 15.16

A double DIEP flap carrying bilateral SIEVs

Fig. 15.17

Revascularization mode. Right deep inferior epigastric vessels to the proximal ends of right internal thoracic artery and vein (1A1V). Right SIEV to the distal vein of right internal mammary vessel. Left deep inferior epigastric vessels to right lateral thoracic artery and vein (1A2V). (1) Proximal thoracic vessels; (2) Right deep inferior epigastric vessels; (3) SIEV; (4) Distal internal thoracic vein; (5) Lateral thoracic vessels; (6) Left deep inferior epigastric vessel

Fig. 15.18

Left mastopexy using round-block method

Fig. 15.19

(a) Intraoperative view immediately after reconstruction. (b) Follow-up at 6 months after operation. (c) Follow-up at 10 months after operation

Fig. 15.20

The patient’s function and appearance recovered satisfactorily

Adverse events of prothesis/expander implant and corresponding solutions:

• 1. Adjustment of capsule space: Patients with prothesis-based breast reconstruction may have asymmetric breasts, which often needs reoperation.

  Expander or prosthesis misplacement, inappropriate volume or size of breast prosthesis, mismatched size of tissue expander, insufficient expansion, and unsatisfactory position are leading reasons for the failure of cavity establishment.

  Corresponding approaches include removal of breast prosthesis or expander, capsulectomy, adjusting IMF, renewing a tissue expander as large as the opposite breast, and implanting a new textured silicone prothesis after adjusting the capsular space.

• 2. Expander/prosthesis upward displacement: expander upward displacement can be usually corrected by capsulotomy at lower breast and separating downward in prosthesis replacement surgery. The upper space of capsule cavity can be closed to prevent the recurrence of prosthesis upward displacement.

  Upward displacement of expander can be easily corrected, the procedure is relatively simple and the postoperative effect is also ideal.

• 3. Expander/prosthesis positioning low: this can be corrected by adjusting the inferior capsule cavity upward. If the position of the inframammary fold is too low, it can be replaced upward simultaneously and reconstructed at a new position.

  It is usually necessary to perform intracavity capsular closure to adjust the capsular space and raise the implant by wall folding suture or horizontal capsulotomy followed by suture using non-absorbable monofilament suture.

• 4. Remodeling the inframammary fold: it is crucial to reconstruct IMF since it directly affects the shape and symmetry of the reconstructed breast.

  In cases of downward displacement of the expander or prosthesis, evaluation of the reconstructed IMF should be conducted when the patient is upright. The descending IMF is raised following implant replacement.

  Before operation, when the patient is standing, the descended IMF is evaluated and where the new IMF should be is determined.

  The IMF is lifted by folding and sewing the redundant capsule on the lower breast.

  If the IMF position is quite low, we can also remove some capsular tissue horizontally, and then close the gap by intracavity approximating the lateral sides with 3-0 Prolene suture. If the IMF is still lower than expected, repeat the above procedure.

  For patients with obesity and thick subcutaneous adipose tissue, the IMF of the reconstructed breast is not so remarkable as that on the opposite side and a larger breast prosthesis is needed.

  The symmetry of bilateral IMFs is very important to breast cosmetology. To achieve symmetry in patients with remarkable IMF line of the healthy breast, the reconstructed IMF should be further lowered by removing focal subcutaneous tissue and interrupted suturing the superficial fascia and the opened inferior capsule.

  Do not resect the entire capsule, otherwise the prosthesis is likely to shift downward when a large-sized prothesis is implanted.

• 5. Lateral or medial displacement of dilator/prosthesis: Naturally, the breast tissue distributes between the para-sternum and the anterior axillary line with fullness on the medial breast.

  Many reconstructed breasts based on implant incline laterally, resulting in reduced fullness on the upper part of the breast and rubbing between the medial arm and the lateral breast. Lateral displacement is probably caused by excessive lateral dissection, or accidental entry of the implant into the previously separated subaxillary cavity, or attraction by lateral tissue and gravity when the patient is in supine position.

  Lateral displacement of the implant can be corrected by suturing the lateral capsule or splitting and reconnecting the lateral capsule to increase the capsular thickness. Two or three rows of capsular suture using non-absorbable suture are commonly used to provide sufficient repair strength and ensure the lasting effect.

  Preoperative markings are made when the patient is standing. The breast prosthesis is manually mobilized to a normal position to outline the range of capsular separation and where capsular suture internally would be.

  Medial displacement of breast prothesis is the most difficult to be dealt with and commonly requires multiple methods including release of the lateral capsule, replacement of prosthesis, and suture of the capsule parallel to the lateral edge of the sternum.

  In almost all cases, capsulectomy is required and the anterior and posterior sides of the capsule are lifted to form capsule valves, subsequently pushing the prothesis laterally to evaluate the adjustment result of medial displacement and making marks on the skin.

• 6. Poor projection of the reconstructed breast: it is commonly improved by replacing with a prothesis of better projection. Focal poor projection is frequently found on the inferior-medial or inferior breast, which can be solved by capsulotomy (a radial or cross-shaped incision at horizontal level), focal capsulectomy, or subtotal capsulectomy.

  The main purpose of these surgical methods is to minimize the pressure and restraint exerted by the capsule on the prosthesis surface.

  However, the tissue covering the prosthesis in patients undergoing breast reconstruction is generally weak and should be taken good care of.

• 7. Skin wrinkles:these often appear in patients with immediate breast reconstruction based on implant and greatly affect the aesthetic effect of the surgery.

  The main reason for skin wrinkle is filling insufficiency by prothesis or tissue. Other reasons include vacancy above the upper pole of the prosthesis, tissue used for cover or filling is insufficient, wrinkles under tension on textured prosthesis, mismatch between breast prosthesis and capsule cavity, etc.

  The breast reconstruction–related skin wrinkles are hardly radically eliminated and are likely to reoccur due to tissue attraction, which should be well informed to patients.

  Wrinkles that are caused by insufficient tissue for cover or filling can be removed by autologous fat grafting.

  We suggest that focal wrinkles together with significant breast deformity or pain due to capsular contracture (Baker IV capsular contracture) are resolved by capsulotomy or capsulectomy and filling with autologous tissue (latissimus dorsi flap, rectus abdominis flap, perforator flap of deep inferior epigastric artery, etc.).

  If skin wrinkles are caused by the mismatch between the size and volume of the prosthesis and the capsule cavity, treatment needs to focus on the mismatched problem.

  It is difficult to repair the wrinkles after breast reconstruction. Treatment usually includes tightening the capsule to slightly change the capsule space, adjustment of the size or the volume or the surface characteristics or all of them of the prosthesis, or increasing the covering tissue with autologous fat grafting.

• 8. Implant leakage and capsular contracture: if implant leakage is not treated in time, the capsular contracture around the implant will occur.

  If capsular contracture occurs, the size and volume of the capsular cavity must be restored by capsular resection.

  These additional procedures also increase the possibility of bilateral breast asymmetry. Therefore, once implant leakage is found, it needs to be treated as soon as possible.

  If silicone gel prosthesis rupture is considered, magnetic resonance imaging is required for evaluation and prosthetic replacement or autologous tissue breast reconstruction is optional. In our center, we prefer rectus abdominis flap or perforator flap of deep inferior epigastric artery or latissimus dorsi myocutaneous flap when reconstruction based on implant fails.

  Capsular contracture is more common and serious in breast reconstruction with prosthesis implantation than in breast augmentation, which may be related to the quality and quantity of the covering tissue. In many patients with breast reconstruction with prosthesis implantation, the covering tissue often gets hard after operation.

  For the treatment of capsular contracture, it is necessary to change the local tissue conditions through capsular resection to provide fresh tissue and a suitable space for the new prosthesis.

  For breast cancer patients undergoing breast reconstruction, we should be cautious with performing capsulectomy because the tissue covering the prosthesis is thin.

• 9. Insufficient tissue for filling or coverage: deficient subcutaneous adipose tissue is often seen in patients receiving breast reconstruction with prosthesis implantation.

  A common situation is that the amount of tissue in the upper part of the breast after prosthesis implantation is insufficient, resulting in a local hollow between above the prosthesis and the surrounding tissue.

  Another situation is that the tissue covering the prosthesis is insufficient leading to poor feeling of the reconstructed breast.

  To solve the above issues, we often perform autologous fat grafting. After stewing and purification, we inject the extracted fat on multiple levels and directions with a blunt needle with a diameter of 1.5–2.0 mm into the depressed area. According to the degree of depression, multiple injections may be required.

  At present, satisfaction survey of breast cancer treatment shows that patients are no longer satisfied with long-term survival and are even hoping to restore the aesthetics of the breast with minimal damage, cost, and hospital stay.

  Contralateral breast adjustment concurrent with unilateral breast reconstruction will not increase surgical complications, however, Asian women are not likely to accept additional surgery simply for aesthetic purposes. Instead, they care greatly about how the surgical outcome can minimize the impact on future work and life. Communication between doctors and patients is very important, and operators should also accurately grasp the surgical indications to obtain satisfactory clinical results.

  We prefer to perform surgical adjustment of the opposite breast simultaneously with unilateral breast reconstruction. Adjustments include breast augmentation, mastopexy, and breast reduction.

  To achieve the symmetrical effect of bilateral breasts, re-operation may be required where adjustment of both the reconstructed breasts and the opposite breast can be performed simultaneously. If cosmetic surgery of the opposite breast is done when the reconstructed breast is well shaped, asymmetry may happen and require one more correction operation.

Case Study 3: Unilateral Breast Reconstruction and Contralateral Mastopexy

The patient, 46 years old, received left modified radical mastectomy plus breast reconstruction with free DIEP flap and adjuvant chemotherapy 10 years ago. In recent years, the bilateral breast asymmetry was increasingly significant featured by the reconstructed breast shrinking. The patient was admitted for left chest wall scar plasty and left nipple reconstruction and left breast fat filling as well as right breast reduction (Figs. 15.21, 15.22, 15.23, 15.24, and 15.25).

Fig. 15.21

Preoperative view

Fig. 15.22

The perforator flap of the inferior epigastric artery with bilateral vascular pedicles was cut off

Fig. 15.23

Intraoperative view immediately after reconstruction

Fig. 15.24

10 years at follow-up after operation

Fig. 15.25

Right mastopexy, left nipple reconstruction, and axillary scar plasty using Z-shaped incision were performed

Case Study 4: Unilateral Breast Reconstruction and Contralateral Mastopexy

A 46 year-old patient received left modified radical mastectomy plus breast reconstruction with free DIEP flap and adjuvant chemotherapy 10 years ago. In recent years, the bilateral breast asymmetry was increasingly significant featured by the reconstructed breast shrinking. The patient was admitted for scar adjustment and left nipple reconstruction and left breast fat filling as well as right breast reduction (Figs. 15.26, 15.27, 15.28, 15.29, and 15.30).

Fig. 15.26

Preoperative view

Fig. 15.27

The right deep inferior epigastric artery and the perforating vessels were separated

Fig. 15.28

Free deep inferior epigastric artery perforator flap was prepared

Fig. 15.29

Left mastopexy was done by round-block method

Fig. 15.30

(a) The blood supply of the flap was good during the operation; (b) 10 days after operation, the patient was discharged with good symmetry and satisfactory appearance of bilateral breasts