Lawrence T. Glickman

The chance of a woman having invasive breast cancer sometime during her life is about one in eight. Many breast cancer patients will consult with a plastic surgeon during their treatment for reconstruction of their breast or breasts, or to repair deformities caused by a lumpectomy operation.

October is Breast Cancer Awareness Month. PSP discussed advances in breast reconstructive techniques with board-certified plastic surgeon Laurence T. Glickman, MD, FACS, MSc, FRCS(C), FACS, of the Long Island Plastic Surgical Group, which is located in Garden City, NY.

WHAT ARE THE DIFFERENT TYPES OF BREAST RECONSTRUCTION PROCEDURES?

Every patient has to be treated individually. Breast reconstruction is a complex procedure that involves multiple variables, which include patient preference, doctor preference, and experience; as well as anatomical issues, such as the patient’s size, availability of autologous tissue, or whether she has other medical problems like diabetes or obesity.

In general, there are several different approaches to breast reconstruction. There are those that involve autologous tissue and those that involve prosthetics. One must consider whether you are doing a unilateral or bilateral breast reconstruction—an important consideration in the reconstruction as well.

In the nonautologous category, I generally do a tissue expander, which is followed by an implant. The third stage would be a nipple-areolar reconstruction. Symmetrizing to the other breast often must be done, which is part of the reconstruction ladder as well.

For autologous reconstructions, I like to do a TRAM Flap. Those can be either unilateral or bilateral, and they can be pedicled or free. There are many different subclassifications of the abdominal skin and muscle free flaps, depending on whether you take skin or without the muscle.

Then there is the latissimus dorsi flap, which is a muscle and skin flap that you harvest from the back and rotate to the chest. An implant is often needed with the latissimus flap as well. This is often done when the abdominal muscle and skin is not available.

Those are the most-often-performed reconstructions for breasts following mastectomy. More recently, I started using Alloderm or Strattice, which is a synthetic dermis. It helps to support the tissues and form the mound for the breast. We’ve been using that for a while.

HOW WOULD YOU CHARACTERIZE THE PATIENT’S SURGERY PREPARATION AND POSTOPERATIVE RECOVERY?

Presurgical consultations and testing will depend on the patient. If the general surgeon is reconstructive-oriented, he or she will introduce the patient to the plastic surgeon and they’ll do the extirpative and reconstructive surgery at the same time. Some patients or surgeons opt not to do that, in which case you’d do a delayed reconstruction. In that case, the patient would have her mastectomy and then, months later, come for their consultation and have their breast reconstruction done in a delayed fashion.

As far as the recovery goes, patients who have the tissue expanders in place following the mastectomy would go home in a day or so. The recovery is relatively straightforward.

An example of a unilateral TRAM flap breast reconstruction, preoperative (left) and postoperative (right).

A TRAM flap, either pedicle or free, is a much bigger operation in terms of the recovery because the abdomen is opened and closed. These patients are in the hospital for a longer time, and it takes about a month or so to recover from these procedures. Recovery from a latissimus flap would be somewhere in between.

HOW HAS YOUR BREAST RECONSTRUCTION SURGERY TECHNIQUE CHANGED OVER THE YEARS?

For tissue expansion and reconstruction using implants, what has changed in the last 15 years would be the availability of silicone routinely, which I prefer. It is a softer implant, particularly when you are putting it under the expanded skin envelope. The saline implants look OK, but they don’t feel as soft as silicone. I prefer silicone; although you still can’t get shaped silicone implants [that] are on protocol.

The use of Alloderm to support the inframammary crease—and have the entire expander and implant covered by tissue—is something that I’ve adopted in the last few years as well. That’s what’s so fascinating about our specialty; it continues to evolve and change. I am doing procedures now that I certainly didn’t learn as a resident. The use of Alloderm is something that has been introduced in the past 5 to 8 years.

One of the other things I have done recently, which I think has been a great advance in breast reconstruction, is called oncoplastic breast reconstruction. In this sense, you are applying plastic surgical principles and aesthetic principles to the reconstructive process. The general surgeons have always made certain elliptical excisions of the breasts when they do a mastectomy so the scar goes across the breast horizontally. That is not necessary because they are leaving skin behind anyway. The ideal situation is that you take all the breast tissue but you leave skin.

We are making every effort to convince our general surgeon colleagues to modify the skin incisions so that the shape of the breast is enhanced and the scar is hidden.

I have been using a technique where the incisions are the same as you would do with a breast-reduction surgery so they are more vertically lined rather than horizontally. That gives you a more conical-shaped breast—a more projecting breast—and the scars ultimately fall in a much nicer place once you are finished with the reconstruction.

Oncoplastic breast reconstruction is something that I think will become very popular. It’s really a question of educating the general surgeons that it’s a safe oncologic procedure. It’s just reorienting the skin incisions.

WHAT ARE YOU NOTICING IN YOUR PRACTICE IN THE WAY OF IMPROVED EARLY-DETECTION TECHNIQUES AND TESTING?

There are more cases now than ever. There are new noninvasive, or at least minimally invasive, procedures—such as breast-sparing procedures where a lumpectomy would be performed with radiation rather than with a mastectomy. A lot of those lumpectomy patients end up with deformities of the breast, which are worse than had they done a mastectomy.

This is an example of a unilateral pedicled TRAM flap with a nipple-areola complex (NAC) reconstruction, preoperative through postoperative (left to right).

We are actually seeing some of those patients later, patients who really need to be reconstructed. More patients are undergoing bilateral mastectomies. There are newer tests: the BRCA 1 and BRCA2 can help screen patients who are at a higher risk for developing cancer in the opposite side. The oncologist and geneticist have helped to identify those patients who are at high risk.

I’m doing more bilateral reconstructions now than ever.

Have skin expanders changed through the years, and what type do you prefer?

I like a skin expander that has a certain teardrop shape to it. I will modify the expander based on the width of the patient’s chest. There are different sizes. I use the McGann expander because it has an integrated port, which I like. Other expanders have a separate port, which you have to bury and place outside the chest in order to use it.

WHAT IS THE MOST COMPLICATED BREAST RECONSTRUCTION CASE YOU’VE DONE?

A young woman presented with left-sided breast cancer and she was very thin, so she was not a candidate for autologous reconstruction. She had a mastectomy. She had no subcutaneous fat, but she had a ptotic breast on the opposite side. So I did a reconstruction with a tissue expander and an implant, and I did a nipple areolar reconstruction on the left side. I also did a mastopexy using an inverted T incision on the right side; she was very nicely symmetric.

Despite having preoperative mammograms and without any evidence of breast cancer, 2 years later she developed breast cancer in the opposite side. The breast surgeon, who was quite conservative, did a horizontal excision of the right breast that crisscrossed the incision that I had made with the previous mastopexy. Reconstructing that breast was difficult because of the scars, but she went through an expansion and a reconstruction and, ultimately, did well.

WHAT IS THE RELATIONSHIP BETWEEN YOU—THE PLASTIC SURGEON—AND THE GENERAL SURGEON?

The relationship between the plastic surgeon, general surgeon, and oncologist is very important. It is crucial for the patient to know that there is good communication between you and the general surgeon. The patient actually ends up seeing the plastic surgeon more often than they see the general surgeon, and we develop a close relationship because we have to do multiple operations on them to get a good reconstruction.

If there is good communication and the patient feels that you are all in control and understand her particular needs and individual diagnosis and treatment options, then not only is there an optimal outcome but the patient has the greatest confidence in you as well.

It’s important that [patients] understand those options as well—the chemotherapy, radiation treatments, the types of chemotherapy, and so forth. It’s really a team effort in order to have the best outcome.

WHAT NEW SCIENCE AND TECHNOLOGIES WILL BE APPLIED TO BREAST RECONSTRUCTION?

There is always research that is ongoing, [such as] developing synthetic products, which can be useful in reconstruction. Whether it’s the expander itself, the breast implant, or other tissue that we use to supplement the patient’s own tissue, new products are always on the horizon. Alloderm and Strattice, for example, are biological, nonantigenic, human or animal-derived dermal substitutes that only recently became available.

There is a lot of research on the availability of off-the-shelf tissues to augment the surgeon’s armamentarium. When you talk about autologous tissues, the development of breast reconstruction using the patient’s own tissue continues to evolve.

When I was training, historically there were pictures of flaps that were marched up the abdomen toward the breast. The plastic surgeon would develop the pedicle flap, keep it attached for three to four, and then detach it and march the tissue up to create the breast. We don’t do that anymore because we do free tissue transfers.

Our specialty is constantly evolving. In the last few years, we have developed newer flaps called muscle-sparing flaps, which don’t require the rectus abdominus muscle to “carry” the skin pedicle. There are other flaps as well, such as the gluteal free flaps, which some reconstructive microsurgeons are still performing.

There is always something on the horizon that’s new and exciting. The DIEP flap has been around for a while, but it’s become more popular because it spares the muscle when you go in to raise the skin from the abdomen to recreate a breast.

The transverse rectus abdominus flap uses the muscle as a carrier for the skin, but there are some patients who suffer from using the muscle. They have weakness of the abdomen or true hernias, and they have a harder time flexing their torso.

The DIEP flap is less invasive and the patients recover more easily, though the actual dissection of the flap is technically more demanding and more difficult to do. The DIEP flap is an excellent choice for an experienced microsurgeon for breast reconstruction.

WHAT IS THE FUTURE OF BREAST RECONSTRUCTIVE SURGERY?

It’s a continuous evolution of techniques. The newer implants have a lower leak rate, they are softer, and they are going to have a nice shape and more options for nonautologous reconstruction.

Autologous reconstruction will continue to evolve as microsurgery becomes more refined, and as instrumentation and intraoperative as well as postoperative monitoring become more sophisticated.

Amy Di Leo is a contributing writer for PSP. She can be reached at [email protected].