Editing Breast reconstruction (section)

==Techniques==
There are several techniques for breast reconstruction.  These options are broadly categorized into two different groups:[[File:Blausen 0138 BreastReconstruction Expander.png|thumb|Breast reconstruction using a tissue expander, which is later replaced by a permanent prosthetic implant.]]

=== Implant-based reconstruction ===
This is the most common technique used worldwide.  Implant-based reconstruction is an option for patients who have sufficient skin after mastectomy to cover a prosthetic implant and allow for a natural shape.  For women undergoing bilateral mastectomies, implants provide the greatest opportunity for symmetrical shape and lift.  Additionally, these procedures are generally much faster than flap-based reconstruction since tissue does not have to be taken from another part of the patient's body.<ref name=":2">{{Cite book|title=Sabiston textbook of surgery : the biological basis of modern surgical practice| vauthors = Townsend Jr CM, Beauchamp RD, Evers BM, Mattox KL |year=2017|isbn=978-0-323-29987-9|edition=20th|location=Philadelphia, PA|pages=865–877|oclc=921338900}}</ref>

Implant-based reconstruction may be one- or two-staged.<ref>{{cite journal | vauthors = Lee KT, Mun GH | title = Comparison of one-stage vs two-stage prosthesis-based breast reconstruction: a systematic review and meta-analysis | journal = American Journal of Surgery | volume = 212 | issue = 2 | pages = 336–344 | date = August 2016 | pmid = 26499053 | doi = 10.1016/j.amjsurg.2015.07.015 }}</ref> In one-stage reconstruction, a permanent implant is inserted at the time of mastectomy. During two-stage reconstruction, the surgeon will insert a [[tissue expansion|tissue expander]] underneath the pectoralis major muscle of the chest wall at the time of mastectomy.<ref>{{cite journal | vauthors = Mannu GS, Navi A, Hussien M | title = Sentinel lymph node biopsy before mastectomy and immediate breast reconstruction does not significantly delay surgery in early breast cancer | journal = ANZ Journal of Surgery | volume = 85 | issue = 6 | pages = 438–443 | date = June 2015 | pmid = 24754896 | doi = 10.1111/ans.12603 | s2cid = 33670281 }}</ref><ref>{{cite journal | vauthors = Mannu GS, Navi A, Morgan A, Mirza SM, Down SK, Farooq N, Burger A, Hussien MI | display-authors = 6 | title = Sentinel lymph node biopsy before mastectomy and immediate breast reconstruction may predict post-mastectomy radiotherapy, reduce delayed complications and improve the choice of reconstruction | journal = International Journal of Surgery | volume = 10 | issue = 5 | pages = 259–264 | year = 2012 | pmid = 22525383 | doi = 10.1016/j.ijsu.2012.04.010 | doi-access = free }}</ref>  This temporary [[silastic]] implant is used to hold tension on the mastectomy flaps.  In doing so, the tissue expander prevents the breast tissue from contracting and allows for use of a larger implant later on compared to what would be safe at the time of the mastectomy.<ref name=":2" />  Following this initial procedure, the patient must return to the clinic on multiple occasions for saline to be injected into a tube inside the tissue expander.  By doing this slowly over the course of several weeks, the space beneath the pectoralis major muscle is safely expanded to an appropriate size without causing too much stress on the breast tissue.  A second procedure is then necessary to remove the tissue expander and replace it with the final, permanent prosthetic implant.<ref>{{Cite web|url=http://www.hopkinsmedicine.org/breast_center/treatments_services/reconstructive_breast_surgery/tissue_expanders.html|title=Tissue Expanders|website=hopkinsmedicine.org}}</ref>

[[File:Blausen 0139 BreastReconstruction Prosthesis.png|thumb|A permanent prosthetic implant eventually replaces the tissue expander.]]Although in the past, prosthetic implants were placed directly under the skin, this method has fallen out of favor because of the greater risk of complications, including visible rippling of the implant and capsular contracture.<ref name=":2" />  The sub-pectoral technique described above is now preferred because it provides an additional muscular layer between the skin and the implant, decreasing the risk of visible deformity.<ref name=":2" />  Oftentimes, however, the pectoralis major muscle is not sufficiently large enough to cover the inferior portion of the prosthetic implant.  If this is the case, one option is to use an acellular dermal matrix to cover the exposed portion of the prosthetic implant, improving both functional and aesthetic outcomes.<ref>{{cite journal | vauthors = Breuing KH, Warren SM | title = Immediate bilateral breast reconstruction with implants and inferolateral AlloDerm slings | journal = Annals of Plastic Surgery | volume = 55 | issue = 3 | pages = 232–239 | date = September 2005 | pmid = 16106158 | doi = 10.1097/01.sap.0000168527.52472.3c | s2cid = 45415084 }}</ref><ref>{{cite journal | vauthors = Salzberg CA | title = Nonexpansive immediate breast reconstruction using human acellular tissue matrix graft (AlloDerm) | journal = Annals of Plastic Surgery | volume = 57 | issue = 1 | pages = 1–5 | date = July 2006 | pmid = 16799299 | doi = 10.1097/01.sap.0000214873.13102.9f | s2cid = 23011518 }}</ref> This prepectoral space has recently, however, come back into practice, with comparable rates of post-operative complications and implant loss to submuscular placement.<ref>{{cite journal | vauthors = Li Y, Xu G, Yu N, Huang J, Long X | title = Prepectoral Versus Subpectoral Implant-Based Breast Reconstruction: A Meta-analysis | language = en-US | journal = Annals of Plastic Surgery | volume = 85 | issue = 4 | pages = 437–447 | date = October 2020 | pmid = 31913902 | doi = 10.1097/SAP.0000000000002190 | s2cid = 210121034 }}</ref><ref>{{cite journal | vauthors = Safran T, Al-Halabi B, Dionisopoulos T | title = Prepectoral Breast Reconstruction: A Growth Story | language = en-US | journal = Plastic and Reconstructive Surgery | volume = 144 | issue = 3 | pages = 525e–527e | date = September 2019 | pmid = 31461069 | doi = 10.1097/PRS.0000000000005924 | doi-access = free }}</ref> Both delayed and direct-to-implant reconstruction in this plane has been shown to be favourable.<ref>{{cite journal | vauthors = Safran T, Al-Halabi B, Viezel-Mathieu A, Boileau JF, Dionisopoulos T | title = Direct-to-Implant, Prepectoral Breast Reconstruction: A Single-Surgeon Experience with 201 Consecutive Patients | language = en-US | journal = Plastic and Reconstructive Surgery | volume = 145 | issue = 4 | pages = 686e–696e | date = April 2020 | pmid = 32221195 | doi = 10.1097/PRS.0000000000006654 | s2cid = 214695100 }}</ref>

Of note, a [[Cochrane review]] published in 2016 concluded that implants for use in breast reconstructive surgery have not been adequately studied in good quality clinical trials. "These days - even after a few million women have had breasts reconstructed – surgeons cannot inform women about the risks and complications of different implant-based breast reconstructive options on the basis of results derived from [[Randomized Controlled Trial]]s."<ref>{{cite journal | vauthors = Rocco N, Rispoli C, Moja L, Amato B, Iannone L, Testa S, Spano A, Catanuto G, Accurso A, Nava MB | display-authors = 6 | title = Different types of implants for reconstructive breast surgery | journal = The Cochrane Database of Systematic Reviews | volume = 2016 | issue = 5 | pages = CD010895 | date = May 2016 | pmid = 27182693 | pmc = 7433293 | doi = 10.1002/14651858.CD010895.pub2 | hdl-access = free | hdl = 2434/442804 }}</ref><ref>{{cite journal | vauthors = Potter S, Conroy EJ, Williamson PR, Thrush S, Whisker LJ, Skillman JM, Barnes NL, Cutress RI, Teasdale EM, Mills N, Mylvaganam S, Branford OA, McEvoy K, Jain A, Gardiner MD, Blazeby JM, Holcombe C | display-authors = 6 | title = The iBRA (implant breast reconstruction evaluation) study: protocol for a prospective multi-centre cohort study to inform the feasibility, design and conduct of a pragmatic randomised clinical trial comparing new techniques of implant-based breast reconstruction | journal = Pilot and Feasibility Studies | volume = 2 | pages = 41 | date = 2016-08-04 | pmid = 27965859 | pmc = 5154059 | doi = 10.1186/s40814-016-0085-8 | doi-access = free }}</ref>

=== Flap-based reconstruction ===
Flap-based reconstruction uses tissue from other parts of the patient's body (i.e., autologous tissue) such as the [[human back|back]], [[buttocks]], [[thigh]] or [[human abdomen|abdomen]].<ref name=":5">{{Cite web |title=Flap Procedures {{!}} Breast Reconstruction Using Your Own Tissue |url=https://www.cancer.org/cancer/breast-cancer/reconstruction-surgery/breast-reconstruction-options/breast-reconstruction-using-your-own-tissues-flap-procedures.html |access-date=2023-04-05 |website=www.cancer.org |language=en}}</ref> In surgery, a "flap" is any type of tissue that is lifted from a donor site and moved to a recipient site using its own blood supply. Usually, the blood supply is a named vessel.  Flap-based reconstruction may be performed either by leaving the donor tissue connected to the original site (also known as a pedicle flap) to retain its blood supply (where the vessels are tunneled beneath the skin surface to the new site) or by cutting the donor tissue's vessels and surgically reconnecting them to a new blood supply at the recipient site (also known as a free flap or free tissue transfer).<ref>{{cite web|title=Breast cancer {{!}} Breast reconstruction using body tissue | work = Cancer Research UK|url=http://www.cancerresearchuk.org/about-cancer/breast-cancer/treatment/surgery/breast-reconstruction/using-body-tissue#collapseListRefeferences }}</ref> The latissimus dorsi is a prime example of such a flap since it can remain attached to its primary blood source which preserves the skins functioning, and is associated with better outcomes in comparison to other muscle and skin donor sites.  <ref>{{Cite journal| vauthors = Hallock G, YoungSang Y |date=2020|title=Left Mastectomy Wound Closure with Left Latissimus Dorsi Musculocutaneous Local Flap |journal=Journal of Medical Insight|language=en-US|doi=10.24296/jomi/290.7|issn=2373-6003}}</ref>

[[File:Blausen 0140 BreastReconstruction TRAM.png|thumb|Transverse Rectus Abdominis Myocutaneous flap (TRAM).]]One option for breast reconstruction involves using the [[latissimus dorsi muscle]] as the donor tissue.<ref name=":5" />  As a back muscle, the latissimus dorsi is large and flat and can be used without significant loss of function.  It can be moved into the breast defect while still attached to its blood supply under the arm pit (axilla). A latissimus flap is often used to recruit soft-tissue coverage over an underlying implant; however, if the latissimus flap can provide enough volume, then occasionally it is used to reconstruct small breasts without the need for an implant.  The latissimus dorsi flap has a number of advantages, but despite the advances in surgical techniques, it has remained vulnerable to skin dehiscence or necrosis at the donor site (on the back).<ref name=":2" /> The Mannu flap is a form of latissimus dorsi flap which avoids this complication by preserving a generous subcutaneous fat layer at the donor site and has been shown to be a safe, simple and effective way of avoiding wound dehiscence at the donor site after extended latissimus dorsi flap reconstruction.<ref>{{cite journal | vauthors = Mannu GS, Farooq N, Down S, Burger A, Hussien MI | title = Avoiding back wound dehiscence in extended latissimus dorsi flap reconstruction | journal = ANZ Journal of Surgery | volume = 83 | issue = 5 | pages = 359–364 | date = May 2013 | pmid = 23088555 | doi = 10.1111/j.1445-2197.2012.06292.x | s2cid = 32228590 }}</ref>

[[File:Blausen 0141 BreastReconstruction TRAM PostOp.png|thumb|Post-operative state after Transverse Rectus Abdominis Myocutaneous flap(TRAM).]]Another possible donor site for breast reconstruction is the abdomen.<ref name=":5"/>  The TRAM (transverse rectus abdominis myocutaneous) flap or its technically distinct variants of microvascular "perforator flaps" like the DIEP/SIEA flaps are all commonly used.  In a TRAM procedure, a portion of the abdominal tissue, which includes skin, subcutaneous fat, minor muscles, and connective tissues, is taken from the patient's abdomen and transplanted to the breast site.  Both TRAM and DIEP/SIEA use the abdominal tissue between the umbilicus (or "belly button") and the pubis. The [[DIEP flap]] and free-TRAM flap require advanced microsurgical technique and are less common as a result. Both can provide enough tissue to reconstruct large breasts and are a good option for patients who would prefer to maintain their pre-operative breast volume. These procedures are preferred by some breast cancer patients because removal of the donor site tissue results in an [[abdominoplasty]] (tummy tuck) and allow the breast to be reconstructed with one's own tissues instead of a prosthetic implant that uses foreign material.  That said, TRAM flap procedures can potentially weaken the abdominal wall and torso strength, but they are generally well tolerated by most patients.<ref name=":2" />  Perforator techniques such as the DIEP (deep inferior epigastric perforator) flap and SIEA (superficial inferior epigastric artery) flap require precise dissection of small perforating vessels through the rectus muscle and, thus, do not require removal of abdominal muscle.  Because of this, these flaps have the advantage of maintaining the majority of abdominal wall strength.

Other donor sites for autologous breast reconstruction include the buttocks, which provides tissue for the SGAP and IGAP (superior and inferior gluteal artery perforator, respectively) flaps.<ref>{{Cite journal | vauthors = Allen RJ, LoTempio MM, Granzow JW |date=May 2006 |title=Inferior Gluteal Perforator Flaps for Breast Reconstruction |journal=Seminars in Plastic Surgery |language=en |volume=20 |issue=2 |pages=089–094 |doi=10.1055/s-2006-941715 |issn=1535-2188 |pmc= 2884781}}</ref> The purpose of perforator flaps (DIEP, SIEA, SGAP, IGAP) is to provide sufficient skin and fat for an aesthetic reconstruction while minimizing post-operative complications from harvesting the underlying muscles. DIEP reconstruction generally produces the best outcome for most women.<ref>{{cite journal | vauthors = Erić M, Mihić N, Krivokuća D | title = Breast reconstruction following mastectomy; patient's satisfaction | journal = Acta Chirurgica Belgica | volume = 109 | issue = 2 | pages = 159–166 | date = 2009-03-01 | pmid = 19499674 | doi = 10.1080/00015458.2009.11680398 | s2cid = 42474582 }}</ref>  See [[free flap breast reconstruction]] for more information.

Mold-assisted reconstruction is a potential adjunctive process to help in flap-based reconstruction.  By using a laser and 3D printer, a patient-specific silicone mold can be used as an aid during surgery, used as a guide for orienting and shaping the flap to improve accuracy and symmetry.<ref>{{cite journal | vauthors = Melchels F, Wiggenhauser PS, Warne D, Barry M, Ong FR, Chong WS, Hutmacher DW, Schantz JT | display-authors = 6 | title = CAD/CAM-assisted breast reconstruction | journal = Biofabrication | volume = 3 | issue = 3 | pages = 034114 | date = September 2011 | pmid = 21900731 | doi = 10.1088/1758-5082/3/3/034114 | url = https://eprints.qut.edu.au/46842/15/46842.pdf | url-status = live | bibcode = 2011BioFa...3c4114M | s2cid = 206108959 | archive-url = https://ghostarchive.org/archive/20221009/https://eprints.qut.edu.au/46842/15/46842.pdf | archive-date = 2022-10-09 }}</ref>