World Journal of Oncology, ISSN 1920-4531 print, 1920-454X online, Open Access
Article copyright, the authors; Journal compilation copyright, World J Oncol and Elmer Press Inc
Journal website https://www.wjon.org

Review

Volume 15, Number 6, December 2024, pages 853-870

Updates on Breast Reconstruction: Surgical Techniques, Challenges, and Future Directions

Figures

Figure 1.
Figure 1. Types of implants and anatomical planes of reconstruction. This figure shows a flowchart of implant types and anatomical planes. In terms of contents, silicone implants are preferred for their softness, while smooth implants are favored due to concerns about breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). For the anatomical plane, the prepectoral option is chosen when the mastectomy flap has sufficient thickness. The use of acellular dermal matrix (ADM) is required in the prepectoral plane.
Figure 2.
Figure 2. Subpectoral reconstruction. The tissue expander (TE) is inserted into the subpectoral plane. After several months of percutaneous saline infusion and gradual expansion, the TE will be replaced with the breast implant.
Figure 3.
Figure 3. Subpectoral reconstruction with acellular dermal matrix (ADM). The pectoralis major muscle is detached inferiorly, and then sutured to the ADM to create a single plane. This eliminates the need for expanding the pectoralis major muscle using a tissue expander (TE), allowing for the implant to be inserted in a single phase.
Figure 4.
Figure 4. Prepectoral reconstruction. The breast implant is entirely covered with acellular dermal matrix (ADM) and inserted at the anterior aspect of pectoralis major muscle. This method is less invasive and becoming more widely used.
Figure 5.
Figure 5. Representative examples of flaps used in autologous breast reconstruction. The LDMC flap is a pedicled myocutaneous flap, while the others are free perforator flaps that require vascular anastomoses. LDMC flap: latissimus dorsi myocutaneous flap; DIEP flap: deep inferior epigastric artery perforator flap; LAP flap: lumber artery perforator flap; PAP flap: profunda artery perforator flap; GAP flap: gluteal artery perforator flap.

Tables

Table 1. Patient Selection Criteria for Breast Reconstruction Methods
 
Breast reconstruction methodImplantsAutologous tissue
This table compares the selection criteria for breast reconstruction using implants versus autologous tissue. The decision on which reconstruction method to use is primarily based on the patient’s preference, with careful consideration of the respective benefits and drawbacks of each method. The implant option involves using synthetic materials, while autologous tissue reconstruction uses the patient’s own tissue. Both methods have distinct advantages and disadvantages that should be discussed with the patient to ensure an informed decision. PROs: patient-reported outcomes; BIA-ALCL: breast implant-associated anaplastic large cell lymphoma.
AdvantagesDo not require a donor siteMinimal maintenance
Less invasiveUndergoing similar age-related changes
Choice of donor based on breast size and body shape
Superior to implants in PROs [10-12]
DisadvantagesRupture [6]Require a donor site
Capsular contracture [6, 7]More invasive
BIA-ALCL [8]Risk of flap loss
Breast implant illness [9]
Inferior to autologous tissue in PROs [10-12]

 

Table 2. Comparison of Different Methods of Implant-Based Reconstruction
 
Types of implantAnatomical plane
ContentsSurface
BIA-ALCL: breast implant-associated anaplastic large cell lymphoma.
Compared to saline implants, silicone implants:Compared to textured implants, smooth implants:Compared to subpectoral implants, prepectoral implants:
Soft ↑ [19]BIA-ALCL ↓ [25]Less invasive
Rupture ↓ [19]Implant rotation ↑ [6]Chronic pain ↓ [26-28]
Cost ↑ [19]Capsular contracture ↑ [16, 21]Animation deformity ↓ [26-28]
Psychosocial well-being ↑ [30]Patient satisfaction ↑ [31]Capsular contracture ↓ [26-28]
Sexual well-being → [30]Easier reconstruction of ptotic breasts [26-28]
Physical well-being → [30]Rippling ↑ [29]
Patient satisfaction → [32]

 

Table 3. History of Autologous Breast Reconstruction
 
Author/yearFlap
LDMC flap: latissimus dorsi myocutaneous flap; TRAM flap: transverse rectus abdominis myocutaneous flap; DIEP flap: deep inferior epigastric artery perforator flap; TUG flap: transverse upper gracilis flap; SGAP flap: superior gluteal artery perforator flap; IGAP flap: inferior gluteal artery perforator flap; SIEA flap: superficial inferior epigastric artery flap; LAP flap: lumber artery perforator flap; PAP flap: profunda artery perforator flap; LD flap: latissimus dorsi flap.
Verneuil, 1887 [51]Pedicled contralateral breast flap
Tansini, 1906 [52]Pedicled LDMC flap
Robbins, 1979 [53]Pedicled TRAM flap
Koshima et al, 1989 [54]Free DIEP flap
Yousif, 1993 [61]Free TUG flap
Allen et al, 1995 [55]Free SGAP flap
Allen et al, 1997 [62]Free IGAP flap
Arnez et al, 1999 [60]Free SIEA flap
De Weerd et al, 2003 [58]Free LAP flap
Allen et al, 2012 [56]Free PAP flap
Selber et al, 2012 [63]Robotic LD flap
Gundlapalli et al, 2018 [64]Robotic DIEP flap
Beugels et al, 2021 [59]Nerve coaptation in DIEP flap
Akita et al, 2024 [57]Scarless LD flap plus lipofilling

 

Table 4. Patient Selection Criteria, Advantages, and Disadvantages for Autologous Tissue Breast Reconstruction
 
Donor site
BackAbdomenThighButtocks
LDMC flap: latissimus dorsi myocutaneous flap; LAP flap: lumber artery perforator flap; DIEP flap: deep inferior epigastric artery perforator flap; TRAM flap: transverse rectus abdominis myocutaneous flap; DIEP flap: deep inferior epigastric artery perforator flap; PAP flap: profunda artery perforator flap; GAP flap: gluteal artery perforator flap.
Flap nameLDMC flap [66]LAP flap [58]DIEP flap [68]TRAM flap [69]PAP flap [56]GAP flap [55, 62]
Flap typeMyocutaneous flapPerforator flapPerforator flapMyocutaneous flapPerforator flapPerforator flap
Patient selection criteriaSmall breastLarge breast (for salvage)Large breastSmall to medium breastLarge breast (alternative for DIEP flap)
Exclusion criteria: desire to have a baby, complicated surgical scars in the abdomen, history of abdominoplasty
AdvantagesDoes not require: 1) vascular anastomosis; 2) dissection of perforatorEase of elevation
Well-concealed scar
Muscle sparing		Large volume so flexibility for breast mound
Abdominoplasty		Muscle sparing
Inconspicuous scar		Large volume
Muscle sparing
Muscle sparing
Less hernia and bulging [54] (than TRAM flap)		Does not require: 1) vascular anastomosis (pedicled TRAM flap);
2) dissection of perforator
DisadvantagesSmall volume
Volume loss due to muscle atrophy
Intraoperative repositioning
Conspicuous scar		Intraoperative repositioning
Short pedicle [67]		Conspicuous scarSmall volumeShort pedicle [70]
Requires: 1) vascular anastomosis; 2) dissection of perforatorVolume loss due to muscle atrophy
Hernia and bulging		Requires: 1) vascular anastomosis; 2) dissection of perforatorIntraoperative repositioning
Requires: 1) vascular anastomosis; 2) dissection of perforator