State of the Art of Breast Reconstruction Techniques

When I think back to my first plastic surgery rotation as a medical student in the early 1990's breast
reconstruction was performed much differently then. During this time period the silicone implant
crisis was at its peak, women were skeptical of breast implants, and the majority of reconstruction
surgeries were with TRAM (Transverse Rectus Abdominus) flaps requiring large skin paddles
because the breast surgeons were much more invasive in the way breasts were removed. Today
silicone breast implants are safe and available in many sizes and shapes, providing patients and
surgeons many more options than ever before. The technique of breast removal (mastectomies) have
become much more selective, even being able to spare the nipple-areolar complex in many cases;
therefore the need to transport new skin into the area is less often required in primary
reconstruction. The advent of soft tissue regeneration with the addition of bio-matrices such as
Acellular dermal matrices and guided tissue regeneration materials such as textile silk meshes have
revolutionized the outcomes in prosthetic reconstruction. Without question one of the greatest
advances in breast reconstruction is the art and science of fat grafting which can augment selected
areas of volume deficiencies, improve the overall shape, and restore the health of the overlying
tissues which has been previously damaged by radiation therapy.

Dr. Pat Maxwell coined the term the bio-engineered breast which utilizes acellular dermal matrix
grafts and fat grafting to rejuvenate the soft tissues surrounding breast implants after mastectomies.
I have been modifying these two techniques in my practice since 2004, which has vastly improved
outcomes in both primary and revision breast reconstruction. Fat grafting has provided plastic
surgeons the ability to selectively sculpt and shape breasts like never before. Implants can only
occupy and provide shape and volume in specific locations on the chest and breast. Fat can influence
any area desired to be modified similar to photo shopping in pictures. Fat already occupies the
majority of a natural breast volume therefore restoring a reconstructed breast to normal form and
function with less donor site morbidity is seen with harvesting large flaps from the abdomen and
buttock region. This truly is an exciting time in plastic surgery to provide excellent results with less
invasive techniques, especially compared to the past.

In addition to the soft tissue restoration procedures the new silicone gel implants have also
contributed to better outcomes. The fifth generation silicone gel implants (Gummy Bear Implant) are
a very cohesive polymer which maintains three dimensional shape. This for me has two advantages;
the first is that we can offer implants which can more easily match a patient's unique chest wall
architecture such as creating an implant narrower in width and taller in height (for a tall thin lady)
or shorter and wider for a small wide chested woman combined with a fuller projection in the lower
half of the breast mirroring a normal breast shape that will have adequate volume but will not
encroach on the arm pit region or have an over expanded upper pole appearance. The second
advantage of these implants are the result of a stiffer polymer which resists forces of capsular
contracture that have been demonstrated to be a major cause of revision breast implant surgery.
With the use of bi-dimensional conceptual planning through meticulous measurements we can offer
a more customized approach to reconstruction and we can educate patients on their options with a
three dimensional imaging system (Vectra) to demonstrate the effect of different shapes and
volumes on their potential outcomes.

Even women who have been diagnosed with breast cancer and elected to undergo breast
conservation techniques with a lumpectomy and radiation therapy can frequently experience
distortions of the breast. The affected breast can shrink in volume and change in shape compared to
its baseline and with the opposite breast as a result of surgical removal of tissue coupled with
imposed radiation fibrosis changes to the tissues which are permanent and progressive. In my
practice I see a number of these women and have been successful in reducing deformities and
restoring shape and volume with the use of internal scar release combined with fat grafting. The
amount of hard woody scarring of the overlying skin can often be suppler after treatment. Contour
deformities which often occur directly in the surgical field where tissue was removed can be
restored in shape and volume leaving a softer breast that is more symmetric with the opposing side.

I am very proud of my field of plastic surgery which by its very nature attracts thoughtful and
innovating disciples of this surgical specialty leading to a continuous evolution of scientific insights
that opens the door for continuous improvements in the care we can provide patients. Breast cancer
reconstruction is just one small piece that is being tackled by our field of study.