Difference between revisions of "Breast reconstruction"
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}}The purpose of breast reconstruction is to restore the shape, symmetry, and appearance of the breast following mastectomy or breast-conserving surgery, with the primary goals of improving quality of life, psychosocial well-being, and body image. Breast reconstruction addresses the physical disfigurement and sense of loss that often follow mastectomy, and is associated with improved psychological, physical, and sexual well-being.<ref>{{Cite journal|last=Bellini|first=Elisa|last2=Pesce|first2=Marianna|last3=Santi|first3=PierLuigi|last4=Raposio|first4=Edoardo|date=2017|title=Two-Stage Tissue-Expander Breast Reconstruction: A Focus on the Surgical Technique|url=https://pubmed.ncbi.nlm.nih.gov/29376067|journal=BioMed Research International|volume=2017|pages=1791546|doi=10.1155/2017/1791546|issn=2314-6141|pmc=5742435|pmid=29376067}}</ref> | }}The purpose of breast reconstruction is to restore the shape, symmetry, and appearance of the breast following mastectomy or breast-conserving surgery, with the primary goals of improving quality of life, psychosocial well-being, and body image. Breast reconstruction addresses the physical disfigurement and sense of loss that often follow mastectomy, and is associated with improved psychological, physical, and sexual well-being.<ref>{{Cite journal|last=Bellini|first=Elisa|last2=Pesce|first2=Marianna|last3=Santi|first3=PierLuigi|last4=Raposio|first4=Edoardo|date=2017|title=Two-Stage Tissue-Expander Breast Reconstruction: A Focus on the Surgical Technique|url=https://pubmed.ncbi.nlm.nih.gov/29376067|journal=BioMed Research International|volume=2017|pages=1791546|doi=10.1155/2017/1791546|issn=2314-6141|pmc=5742435|pmid=29376067}}</ref> | ||
Reconstruction can be performed using implant-based or autologous tissue techniques, and the choice is individualized based on patient characteristics, cancer treatment plan, and preferences.<ref>{{Cite journal|last=Gerber|first=Bernd|last2=Marx|first2=Mario|last3=Untch|first3=Michael|last4=Faridi|first4=Andree|date=2015-08-31|title=Breast Reconstruction Following Cancer Treatment|url=https://pubmed.ncbi.nlm.nih.gov/26377531|journal=Deutsches Arzteblatt International|volume=112|issue=35-36|pages=593–600|doi=10.3238/arztebl.2015.0593|issn=1866-0452|pmc=4577667|pmid=26377531}}</ref> | |||
==Overview== | ==Overview== | ||
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|- | |- | ||
|Pulmonary | |Pulmonary | ||
| | |respiratory compromise can be present if pt had XRT to thorax | ||
|- | |- | ||
|Gastrointestinal | |Gastrointestinal | ||
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===Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. -->=== | ===Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. -->=== | ||
===Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. -->=== | ===Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. -->=== | ||
The most established regional techniques are thoracic paravertebral block (PVB), pectoral nerve blocks (PECS I and II), serratus anterior plane (SAP) block, and erector spinae plane (ESP) block. | |||
* Thoracic paravertebral block (PVB) has overwhelming evidence in both prosthetic and autologous breast reconstruction with a low complication rate: it provides significant reductions in postoperative pain, opioid consumption, nausea, and length of stay. PVB is particularly effective for mastectomy with or without reconstruction, and is often preferred when lymph node dissection or flap-based reconstruction is planned. However, it is technically more challenging and carries a higher perceived risk compared to other blocks.<ref>{{Cite journal|last=Calì Cassi|first=L.|last2=Biffoli|first2=F.|last3=Francesconi|first3=D.|last4=Petrella|first4=G.|last5=Buonomo|first5=O.|date=2017-03|title=Anesthesia and analgesia in breast surgery: the benefits of peripheral nerve block|url=https://pubmed.ncbi.nlm.nih.gov/28387892|journal=European Review for Medical and Pharmacological Sciences|volume=21|issue=6|pages=1341–1345|issn=2284-0729|pmid=28387892}}</ref><ref>{{Cite journal|last=FitzGerald|first=Simon|last2=Odor|first2=Peter M.|last3=Barron|first3=Ann|last4=Pawa|first4=Amit|date=2019-03|title=Breast surgery and regional anaesthesia|url=https://pubmed.ncbi.nlm.nih.gov/31272657|journal=Best Practice & Research. Clinical Anaesthesiology|volume=33|issue=1|pages=95–110|doi=10.1016/j.bpa.2019.03.003|issn=1878-1608|pmid=31272657}}</ref> | |||
* Pectoral nerve blocks (PECS I and II) and serratus anterior plane blocks are easier to perform and demonstrate efficacy in reducing pain and opioid requirements, especially in implant-based and flap-based reconstructions. These blocks are increasingly favored for their safety profile and versatility, and can be combined with PVB for extensive procedures.<ref>{{Cite journal|last=Abi-Rafeh|first=Jad|last2=Safran|first2=Tyler|last3=Abi-Jaoude|first3=Joanne|last4=Kazan|first4=Roy|last5=Alabdulkarim|first5=Abdulaziz|last6=Davison|first6=Peter G.|date=2022-07-01|title=Nerve Blocks in Breast Plastic Surgery: Outcomes, Complications, and Comparative Efficacy|url=https://pubmed.ncbi.nlm.nih.gov/35499513|journal=Plastic and Reconstructive Surgery|volume=150|issue=1|pages=1e–12e|doi=10.1097/PRS.0000000000009253|issn=1529-4242|pmid=35499513}}</ref><ref>{{Cite journal|last=Matsumoto|first=Marcio|last2=Flores|first2=Eva M.|last3=Kimachi|first3=Pedro P.|last4=Gouveia|first4=Flavia V.|last5=Kuroki|first5=Mayra A.|last6=Barros|first6=Alfredo C. S. D.|last7=Sampaio|first7=Marcelo M. C.|last8=Andrade|first8=Felipe E. M.|last9=Valverde|first9=João|last10=Abrantes|first10=Eduardo F.|last11=Simões|first11=Claudia M.|date=2018-05-18|title=Benefits in radical mastectomy protocol: a randomized trial evaluating the use of regional anesthesia|url=https://pubmed.ncbi.nlm.nih.gov/29777144|journal=Scientific Reports|volume=8|issue=1|pages=7815|doi=10.1038/s41598-018-26273-z|issn=2045-2322|pmc=5959858|pmid=29777144}}</ref> | |||
* Erector spinae plane block is an emerging technique with promising results, but less extensive data compared to PVB and PECS blocks.<ref>{{Cite journal|last=Wong|first=Heung-Yan|last2=Pilling|first2=Rob|last3=Young|first3=Bruce W. M.|last4=Owolabi|first4=Adetokunbo A.|last5=Onwochei|first5=Desire N.|last6=Desai|first6=Neel|date=2021-09|title=Comparison of local and regional anesthesia modalities in breast surgery: A systematic review and network meta-analysis|url=https://pubmed.ncbi.nlm.nih.gov/33873002|journal=Journal of Clinical Anesthesia|volume=72|pages=110274|doi=10.1016/j.jclinane.2021.110274|issn=1873-4529|pmid=33873002}}</ref> | |||
* Regional anesthesia techniques do not adversely affect flap perfusion or hemodynamics. | |||
==Intraoperative management== | ==Intraoperative management== | ||
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===Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. -->=== | ===Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. -->=== | ||
For both implant-based and autologous reconstructions, the patient is typically placed in the supine position with both arms abducted to less than 90 degrees (access and minimize brachial plexus injury risk). | |||
For autologous flap procedures (e.g., DIEP, TRAM, or latissimus dorsi flaps), may need to potentially prone patient (will flip from prone to supine during graft harvest) or may need access to abdominal wall depending on planned flap type. | |||
===Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. -->=== | ===Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. -->=== | ||
For implant-based reconstruction, the operative plane (prepectoral vs. subpectoral) affects anesthetic requirements, with prepectoral placement associated with lower perioperative opioid and antiemetic needs. | |||
===Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. -->=== | ===Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. -->=== | ||
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===Potential complications<!-- List and/or describe any potential postoperative complications for this case. -->=== | ===Potential complications<!-- List and/or describe any potential postoperative complications for this case. -->=== | ||
Major complications—those requiring rehospitalization or reoperation—are more frequent with autologous techniques, especially in the setting of higher BMI, comorbidities, or radiotherapy. Radiation therapy increases the risk of infection, implant loss, and fat necrosis, particularly in the late postoperative period.<ref>{{Cite journal|last=Bennett|first=Katelyn G.|last2=Qi|first2=Ji|last3=Kim|first3=Hyungjin M.|last4=Hamill|first4=Jennifer B.|last5=Pusic|first5=Andrea L.|last6=Wilkins|first6=Edwin G.|date=2018-10-01|title=Comparison of 2-Year Complication Rates Among Common Techniques for Postmastectomy Breast Reconstruction|url=https://doi.org/10.1001/jamasurg.2018.1687|journal=JAMA Surgery|volume=153|issue=10|pages=901–908|doi=10.1001/jamasurg.2018.1687|issn=2168-6254}}</ref> | |||
* Seroma | |||
* Hematoma | |||
* Implant reconstruction: | |||
** Capsular contracture | |||
** Implant malposition / rupture / leakage | |||
* Autologous reconstruction: | |||
** Flap thrombosis can lead to necrosis | |||
*** monitoring for flap perfusion is critical in autologous reconstruction | |||
** Fat necrosis | |||
** Hernia | |||
==Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). -->== | ==Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). -->== | ||
Revision as of 14:19, 22 July 2025
Breast reconstruction
| Anesthesia type | |
|---|---|
| Airway | |
| Lines and access | |
| Monitors | |
| Primary anesthetic considerations | |
| Preoperative | |
| Intraoperative | |
| Postoperative | |
| Article quality | |
| Editor rating | |
| User likes | 0 |
The purpose of breast reconstruction is to restore the shape, symmetry, and appearance of the breast following mastectomy or breast-conserving surgery, with the primary goals of improving quality of life, psychosocial well-being, and body image. Breast reconstruction addresses the physical disfigurement and sense of loss that often follow mastectomy, and is associated with improved psychological, physical, and sexual well-being.[1]
Reconstruction can be performed using implant-based or autologous tissue techniques, and the choice is individualized based on patient characteristics, cancer treatment plan, and preferences.[2]
Overview
Indications
Surgical procedure
Preoperative management
Patient evaluation
| System | Considerations |
|---|---|
| Airway | |
| Neurologic | |
| Cardiovascular | |
| Pulmonary | respiratory compromise can be present if pt had XRT to thorax |
| Gastrointestinal | |
| Hematologic | |
| Renal | |
| Endocrine | |
| Other |
Labs and studies
Operating room setup
Patient preparation and premedication
Regional and neuraxial techniques
The most established regional techniques are thoracic paravertebral block (PVB), pectoral nerve blocks (PECS I and II), serratus anterior plane (SAP) block, and erector spinae plane (ESP) block.
- Thoracic paravertebral block (PVB) has overwhelming evidence in both prosthetic and autologous breast reconstruction with a low complication rate: it provides significant reductions in postoperative pain, opioid consumption, nausea, and length of stay. PVB is particularly effective for mastectomy with or without reconstruction, and is often preferred when lymph node dissection or flap-based reconstruction is planned. However, it is technically more challenging and carries a higher perceived risk compared to other blocks.[3][4]
- Pectoral nerve blocks (PECS I and II) and serratus anterior plane blocks are easier to perform and demonstrate efficacy in reducing pain and opioid requirements, especially in implant-based and flap-based reconstructions. These blocks are increasingly favored for their safety profile and versatility, and can be combined with PVB for extensive procedures.[5][6]
- Erector spinae plane block is an emerging technique with promising results, but less extensive data compared to PVB and PECS blocks.[7]
- Regional anesthesia techniques do not adversely affect flap perfusion or hemodynamics.
Intraoperative management
Monitoring and access
Induction and airway management
Positioning
For both implant-based and autologous reconstructions, the patient is typically placed in the supine position with both arms abducted to less than 90 degrees (access and minimize brachial plexus injury risk).
For autologous flap procedures (e.g., DIEP, TRAM, or latissimus dorsi flaps), may need to potentially prone patient (will flip from prone to supine during graft harvest) or may need access to abdominal wall depending on planned flap type.
Maintenance and surgical considerations
For implant-based reconstruction, the operative plane (prepectoral vs. subpectoral) affects anesthetic requirements, with prepectoral placement associated with lower perioperative opioid and antiemetic needs.
Emergence
Postoperative management
Disposition
Pain management
Potential complications
Major complications—those requiring rehospitalization or reoperation—are more frequent with autologous techniques, especially in the setting of higher BMI, comorbidities, or radiotherapy. Radiation therapy increases the risk of infection, implant loss, and fat necrosis, particularly in the late postoperative period.[8]
- Seroma
- Hematoma
- Implant reconstruction:
- Capsular contracture
- Implant malposition / rupture / leakage
- Autologous reconstruction:
- Flap thrombosis can lead to necrosis
- monitoring for flap perfusion is critical in autologous reconstruction
- Fat necrosis
- Hernia
- Flap thrombosis can lead to necrosis
Procedure variants
| Variant 1 | Variant 2 | |
|---|---|---|
| Unique considerations | ||
| Indications | ||
| Position | ||
| Surgical time | ||
| EBL | ||
| Postoperative disposition | ||
| Pain management | ||
| Potential complications |
References
- ↑ Bellini, Elisa; Pesce, Marianna; Santi, PierLuigi; Raposio, Edoardo (2017). "Two-Stage Tissue-Expander Breast Reconstruction: A Focus on the Surgical Technique". BioMed Research International. 2017: 1791546. doi:10.1155/2017/1791546. ISSN 2314-6141. PMC 5742435. PMID 29376067.
- ↑ Gerber, Bernd; Marx, Mario; Untch, Michael; Faridi, Andree (2015-08-31). "Breast Reconstruction Following Cancer Treatment". Deutsches Arzteblatt International. 112 (35–36): 593–600. doi:10.3238/arztebl.2015.0593. ISSN 1866-0452. PMC 4577667. PMID 26377531.
- ↑ Calì Cassi, L.; Biffoli, F.; Francesconi, D.; Petrella, G.; Buonomo, O. (2017-03). "Anesthesia and analgesia in breast surgery: the benefits of peripheral nerve block". European Review for Medical and Pharmacological Sciences. 21 (6): 1341–1345. ISSN 2284-0729. PMID 28387892. Check date values in:
|date=(help) - ↑ FitzGerald, Simon; Odor, Peter M.; Barron, Ann; Pawa, Amit (2019-03). "Breast surgery and regional anaesthesia". Best Practice & Research. Clinical Anaesthesiology. 33 (1): 95–110. doi:10.1016/j.bpa.2019.03.003. ISSN 1878-1608. PMID 31272657. Check date values in:
|date=(help) - ↑ Abi-Rafeh, Jad; Safran, Tyler; Abi-Jaoude, Joanne; Kazan, Roy; Alabdulkarim, Abdulaziz; Davison, Peter G. (2022-07-01). "Nerve Blocks in Breast Plastic Surgery: Outcomes, Complications, and Comparative Efficacy". Plastic and Reconstructive Surgery. 150 (1): 1e–12e. doi:10.1097/PRS.0000000000009253. ISSN 1529-4242. PMID 35499513 Check
|pmid=value (help). - ↑ Matsumoto, Marcio; Flores, Eva M.; Kimachi, Pedro P.; Gouveia, Flavia V.; Kuroki, Mayra A.; Barros, Alfredo C. S. D.; Sampaio, Marcelo M. C.; Andrade, Felipe E. M.; Valverde, João; Abrantes, Eduardo F.; Simões, Claudia M. (2018-05-18). "Benefits in radical mastectomy protocol: a randomized trial evaluating the use of regional anesthesia". Scientific Reports. 8 (1): 7815. doi:10.1038/s41598-018-26273-z. ISSN 2045-2322. PMC 5959858. PMID 29777144.
- ↑ Wong, Heung-Yan; Pilling, Rob; Young, Bruce W. M.; Owolabi, Adetokunbo A.; Onwochei, Desire N.; Desai, Neel (2021-09). "Comparison of local and regional anesthesia modalities in breast surgery: A systematic review and network meta-analysis". Journal of Clinical Anesthesia. 72: 110274. doi:10.1016/j.jclinane.2021.110274. ISSN 1873-4529. PMID 33873002. Check date values in:
|date=(help) - ↑ Bennett, Katelyn G.; Qi, Ji; Kim, Hyungjin M.; Hamill, Jennifer B.; Pusic, Andrea L.; Wilkins, Edwin G. (2018-10-01). "Comparison of 2-Year Complication Rates Among Common Techniques for Postmastectomy Breast Reconstruction". JAMA Surgery. 153 (10): 901–908. doi:10.1001/jamasurg.2018.1687. ISSN 2168-6254.
Top contributors: Sarah Glier