2021 CSBrS Practice Guidelines: Breast Reconstruction after Mastectomy
1. Introduction
Breast cancer is one of the most common malignancies among women. Mastectomy is a frequently used treatment method, but it often has a significant impact on a woman's body image and psychological well - being. Breast reconstruction after mastectomy aims to restore the breast's appearance, helping patients regain confidence and improve their quality of life. The 2021 CSBrS (presumably a relevant professional society) Practice Guidelines are developed to provide evidence - based recommendations for optimal breast reconstruction after mastectomy.
2. Pre - operative Evaluation
2.1 Patient - related Factors
Medical History
Thoroughly review the patient's past medical history, including any pre - existing comorbidities such as diabetes, cardiovascular diseases, and autoimmune disorders. These conditions can affect the patient's surgical tolerance and the risk of postoperative complications. For example, diabetes may increase the risk of wound infection and poor wound healing.
Document the patient's smoking history. Smoking is a well - known risk factor for flap necrosis in autologous tissue breast reconstruction. Patients are advised to quit smoking at least 4 weeks before surgery to reduce this risk.
Inquire about the patient's family history of breast cancer or other genetic syndromes. Genetic factors may influence the type of breast cancer and potentially the choice of reconstruction method.
Cancer - related Information
Determine the stage of breast cancer. The stage can impact the timing and type of breast reconstruction. For example, in some advanced - stage cases, neoadjuvant therapy may be required first, and the reconstruction may be delayed until the cancer is under control.
Understand the tumor location within the breast. Tumors in certain locations may require more extensive resection, which can affect the feasibility of different reconstruction techniques.
Know the histological type and molecular subtype of breast cancer. These factors can influence the postoperative adjuvant therapy plan, and some therapies may have implications for breast reconstruction.
2.2 Psychological Evaluation
Assess the patient's psychological state and their expectations of breast reconstruction. A positive psychological attitude and realistic expectations are crucial for a successful reconstruction outcome. Psychological support should be provided as needed, either through counseling services or support groups.
Use standardized psychological assessment tools if possible to objectively evaluate the patient's anxiety, depression, and body image dissatisfaction levels. This can help in tailoring appropriate psychological interventions.
3. Types of Breast Reconstruction
3.1 Autologous Tissue Reconstruction
Latissimus Dorsi Flap
Indication：This flap is suitable for patients with a relatively small - to - medium - sized breast or those who need additional soft - tissue coverage. It can be used in immediate or delayed reconstruction.
Advantages：It provides a good amount of soft tissue, and the donor - site morbidity is relatively low. The flap can be easily harvested, and it has a reliable blood supply.
Disadvantages：The volume of the flap may be limited for large - breast reconstruction. There may be some cosmetic issues at the donor site, such as a visible scar and muscle weakness in the long - term.
Transverse Rectus Abdominis Myocutaneous (TRAM) Flap
Indication：Ideal for patients with sufficient abdominal tissue, especially those with a larger - sized breast. It can be used for both immediate and delayed reconstruction.
Advantages：It offers a large amount of tissue for breast reconstruction, resulting in a more natural - looking breast. The abdominal tissue has a similar texture to breast tissue.
Disadvantages：The donor - site morbidity is relatively high, including potential abdominal wall weakness, hernia formation, and a significant abdominal scar.
Deep Inferior Epigastric Perforator (DIEP) Flap
Indication：Similar to the TRAM flap, it is suitable for patients with adequate abdominal tissue. It is a popular choice for many patients due to its good cosmetic outcome.
Advantages：It preserves the rectus abdominis muscle, reducing the risk of abdominal wall weakness and hernia compared to the TRAM flap. It provides a large amount of well - vascularized tissue for a natural - looking breast reconstruction.
Disadvantages：The surgical technique is more complex, requiring microsurgical skills to anastomose the blood vessels. There is a risk of flap failure due to vascular complications.
3.2 Implant - based Reconstruction
Tissue Expander and Implant
Indication：This is a common choice for patients who do not want to undergo autologous tissue harvesting or those with limited autologous tissue. It can be used in immediate or delayed reconstruction.
Advantages：The surgical procedure is relatively less invasive compared to autologous tissue reconstruction. It has a shorter operating time, and the recovery time may be quicker.
Disadvantages：There is a risk of implant - related complications such as capsular contracture, infection, and implant rupture. The long - term durability of the implant may also be a concern.
Direct - to - Implant Reconstruction
Indication：Suitable for patients with a good skin envelope and minimal need for tissue expansion. It is often considered in cases where the breast skin can directly accommodate the implant.
Advantages：It simplifies the reconstruction process, reducing the number of surgical procedures. It can provide a more immediate breast - like appearance.
Disadvantages：There is a higher risk of implant - related complications, especially in patients with a thin skin envelope. The risk of implant exposure and poor cosmetic outcome may be increased.
4. Timing of Breast Reconstruction
4.1 Immediate Reconstruction
Advantages
It can provide immediate psychological benefits to the patient, as they do not have to experience the psychological stress of living without a breast.
It may result in a better cosmetic outcome, as the reconstruction can be tailored to the original breast shape and size before the effects of tissue contraction and scarring occur.
There may be cost - effectiveness in terms of reducing the overall number of hospitalizations and surgical procedures.
Disadvantages
There is a potential risk of delaying adjuvant therapy if there are complications from the reconstruction.
The decision - making process may be more rushed, as the patient has to make choices about reconstruction while also dealing with the diagnosis of breast cancer.
4.2 Delayed Reconstruction
Advantages
It allows for a more comprehensive evaluation of the patient's cancer status and completion of adjuvant therapies. This can reduce the risk of interference between reconstruction and cancer treatment.
The patient has more time to consider their options and make a more informed decision about reconstruction.
Disadvantages
The patient has to live without a breast for a period, which can cause psychological distress.
There may be more complex surgical challenges due to tissue contracture and scarring in the mastectomy site.
5. Post - operative Management
5.1 Wound Care
Monitor the surgical wound closely for signs of infection, such as redness, swelling, warmth, and purulent discharge. Keep the wound clean and dry, and change the dressing regularly according to the hospital's protocol.
In the case of autologous tissue reconstruction, pay special attention to the flap's blood supply. Observe the color, temperature, and capillary refill of the flap. Any signs of poor perfusion should be reported immediately to the surgical team.
5.2 Complications Management
Autologous Tissue Reconstruction
Flap Necrosis：If flap necrosis is suspected, immediate intervention may be required, which may include surgical exploration to salvage the flap or remove the necrotic tissue.
Hematoma and Seroma：These can be managed by drainage, either through needle aspiration or surgical evacuation. Prophylactic measures such as proper hemostasis during surgery and the use of drains can help reduce the risk.
Implant - based Reconstruction
Capsular Contracture：Treatment options may include massage, steroid injection, or surgical removal of the capsule. Prevention measures include using textured implants and proper implant placement.
Infection：In case of implant infection, antibiotics may be prescribed. In severe cases, the implant may need to be removed, and the reconstruction may need to be delayed until the infection is resolved.
5.3 Follow - up
Schedule regular follow - up appointments for the patient. In the early post - operative period, follow - up may be more frequent, such as weekly or bi - weekly, to monitor wound healing and flap or implant status.
Long - term follow - up should also be carried out to assess the long - term cosmetic outcome, detect any late - onset complications, and provide psychological support as needed. The frequency of long - term follow - up can be every 3 - 6 months for the first few years and then less frequently as the patient's condition stabilizes.
6. Conclusion
Breast reconstruction after mastectomy is a complex but rewarding procedure. By following these 2021 CSBrS Practice Guidelines, surgeons can provide high - quality care to breast cancer patients, helping them achieve a better physical and psychological recovery. The guidelines emphasize the importance of a comprehensive pre - operative evaluation, appropriate choice of reconstruction type and timing, and meticulous post - operative management.