Breast reconstruction

Abstract

The presence of breasts is a defining feature of adult mammalian gender. It must therefore be considered an essential element of human femininity, and the role it plays in female psychology cannot be understated. 1,2 The requirement for reconstruction of the female breast is almost exclusively consequent on breast surgery for breast cancer.Providers are becoming legally bound to educate and prepare patients who require mastectomy for reconstruction, such that informed choices can be made. They are obliged to offer a mul tidisciplinary setting as part of a care pathway, in particular allowing for cross-specialty engagement to allow for immediate reconstruction. The surgery of reconstruction has become a recognized specialist area, which by virtue of its appreciation of three-dimensional form, and its possible call on microsurgical skills, naturally falls within the domain and skill set of the plastic surgeon.In this chapter the techniques of breast reconstruction and the principles behind them are reviewed, and it is hoped this will offer the practitioner a ready reference for what we trust will be a meticulously if not passionately executed endeavour. reconstructive aimsAny attempt at reconstruction should appreciate the nuances of breast form, volume and its complex three dimensionality. Its position on the chest wall is determined by its footprint, 3-5 a fixed entity that does not change with age, and that is set by the inframammary fold (IMF) at the 6-7th rib inferiorly, the 2nd rib superiorly, 1-2 cm behind the anterior axillary line laterally, and the lateral border of the sternum medially. The footprint sets the basic breast position on the chest, and by complementing the opposite side creates the necessary foundation for symmetry.The breast conus represents the tissue that projects from the chest wall, a complex of skin envelope with its glandular and fatty content that falls inferiorly to a variable extent over the IMF in a manner termed ptosis. Unlike the footprint, the conus is variable with age. Creating, therefore, a symmetrical ptotic conus precisely positioned on the breast footprint embodies the art of breast reconstructive sculpture. The skin envelope aids in determining shape and any damage or removal of skin will influence its final shape. The ultimate goal of breast reconstruc tion is to create symmetrical, natural-looking breasts and not necessarily a specific shape or volume. aesthetic and functional considerationsBreast ideals have changed over time, as depicted in art and reflecting past and existing cultural differences. There is also a potential variation between what the surgeon and the patient perceives as aesthetic. For this reason it is critical to be attentive to the patient's wishes, appreciating that simple breast symmetry rather than an idealized form may well be their preference.However, insofar as it is possible to specify what an ideal breast should be, the following can be stated: 6 • Breast size relates to the size and shape of the torso.• Nipple placement is critical -ideall...

Thoracoacromial artery perforator flap based on the clavicular branch: A new option in regional reconstruction

“…9 If the defect does not extend the full thickness of the anterior chest wall, and bony or vital structures are not exposed, the soft tissue defect could be closed with a skin graft, local axial pedicled or randomized skin flaps, tissue expansion and skin advancement. 16 Thoracodorsal, intercostal or internal mammary artery perforator flaps could also be used for the reconstruction. If the soft tissue defect involves an exposed bony structure, but no other exposed vital structure, thin, well-vascularized skin flaps can provide durable reconstruction with better contour and texture.…”

“…If the soft tissue defect involves an exposed bony structure, but no other exposed vital structure, thin, well-vascularized skin flaps can provide durable reconstruction with better contour and texture. 16 Reconstruction with free flaps might be necessary for large defects resulting from tumour resection when regional pedicles have been destroyed or are not available. 12 Although squamous cell carcinoma is common, it is rare in the anterior thorax.…”