The desire of every woman who has breast cancer is both to get rid of the cancer and not to lose her breast. However, because of the life-threatening feature of cancer for years, only getting rid of cancer was prioritized, and repair attempts were put in the second stage. As a result of breast loss, many psycho-social problems such as depression and affective disorder, loss of sexual desire, deterioration in body perception, fear of losing femininity, concerns about recurrence of the disease, difficulty in finding suitable clothes and problems caused by externally applied breast prostheses in the form of bras are seen in women. Thanks to a better understanding of breast cancer biology and advances in surgical techniques, immediate or late breast reconstruction after mastectomy is now possible for most women with breast cancer. These developments have promoted the results of breast reconstruction to be dramatically improved, patients’ acceptance of breast repair and their expectations to change.

The aim of breast reconstruction should be:

• The new breast should have a similar appearance and structure to the intact breast.
• Allow early chemotherapy and radiotherapy
• Should not increase the risk of local recurrence
• It should not increase the risk of distant metastases.

Effect of Mastectomy Type on Repair Technique

Undoubtedly, the development of mastectomy techniques has had the greatest impact on the application of breast reconstruction to more and more patients. In recent years, breast surgeons have turned from the “take as much as you can” philosophy to the “take what is necessary” philosophy. As a result, with the developments in the multidisciplinary approach, more and more conservative mastectomies have been applied. Studies have repeatedly shown that the risk of local recurrence and development of secondary cancer is similar between patients who underwent mastectomy alone and those who underwent breast reconstruction. In addition, some studies have shown that the mortality rate and the rate of distant metastases tend to decrease in patients who underwent breast reconstruction.

As a result of the experience gained with different interventions, the indications for breast reconstruction have expanded. The devastating emotional impact of mastectomy can be reduced by early reconstruction. Early reconstruction following ablative intervention resulted in a reduction in the incidence of post-mastectomy depression. Early reconstruction in such a surgical approach is attractive because the skin flaps are flexible and the inframammary line is easy to preserve. Thus, immediate breast reconstruction provides an undisputed cosmetic advantage.

It is believed that reconstruction techniques are not prohibitive in the treatment of primary cancer, once it is understood that patient survival is largely dependent on control of the disease at the initial stage. Many authors reported that the implant used in the reconstruction was not affected by chemotherapy. Similarly, the implant neither blocks nor enhances radiation ablation. Likewise, there is no evidence that silicone-containing prostheses harm body immunology. On the other hand, temporary immunosuppression triggered by a second operation, such as late reconstruction, can stimulate occult tumor cells. When deciding on early reconstruction after mastectomy, the side effects of early reconstruction on the breast should be evaluated considering the current situation of the patient. Some neoplastic agents, such as Adriamycin, are known to definitively inhibit wound healing. This situation can be considered as a hindering factor for early reconstruction and may be a reason to perform the operation after chemotherapy. Similarly, in patients receiving adjuvant radiotherapy, reconstruction tends to be delayed after radiotherapy. However, there are many publications in the literature that an increasing rate of early repair is performed with adjuvant therapy and that the precautions for possible complications are sufficient. Radiotherapy may cause fat necrosis in the autogenous tissue flap and encapsulate around the prosthesis.
When skin-sparing mastectomy is compared with conventional mastectomy, it has been shown that there is no increase in local recurrence and better aesthetic results are obtained after early reconstruction. In addition, breast reconstruction techniques used today do not prevent the monitoring of local recurrence.

Instant and Late Repair Selection

In the patient for whom mastectomy is planned, first of all, it should be decided whether the breast repair will be done immediately or in the late period. In general, any woman who will undergo or have had a mastectomy before is a potential postmastectomy breast repair candidate. However, there is a tendency to apply repair surgeries during mastectomy to patients with early-stage tumors. The patient’s choice and expectation should be fully questioned. Most women decide on this issue based on what they hear from their family and friends or their experiences. If late reconstruction is decided, 3-6 months should be waited for the soft tissue to heal.

If radiotherapy is planned, autologous tissue transfer can be delayed until the end of radiotherapy. Because after radiotherapy is applied, the aesthetic result obtained at the beginning may be affected because of the extensive damage to the skin and subcutaneous tissue by the radiation. However, chemotherapy has no significant effect on the timing or outcomes of breast reconstruction.

Immediate reconstruction offers many advantages over delayed reconstruction. In addition to obtaining a superior cosmetic result, the risks of anesthesia and higher cost of a two-stage treatment are avoided. The belief that patients accept to live with the defect formed after mastectomy under conditions where reconstruction is possible has changed. Immediate reconstruction now provides a better body contour where the breast mass is preserved as much as possible. Delayed repairs require remodeling of the previous defect and are often accompanied by visible scar tissue. In addition, a pre-cut pedicle may limit the surgical intervention of choice. Simultaneous ablation and immediate breast reconstruction are safe and provide a better aesthetic result.

Autologous Tissue – Implant Selection

After immediate or delayed reconstruction is selected, the method to be used for this procedure should be decided. Adequate soft tissue may allow the application of the tissue expansion technique for both immediate and delayed reconstruction. If soft tissue support is inadequate and radical mastectomy was performed to involve the pectoralis major muscle, autologous tissue is required to fill the defect in the chest wall.

Different methods can be used to achieve symmetry with the contralateral breast during breast reconstruction after mastectomy. Submuscular implant reconstruction may be ideal for small or medium-sized breasts. In these examples, the implant size should be between 200-400 cc. In unilateral reconstruction of large breasts, symmetry is best achieved with autogenous tissue, especially if there is ptosis in the contralateral breast. In cases where autogenous tissue reconstruction is contraindicated, the best symmetry is sought with implant reconstruction and simultaneous or delayed breast reduction mammaplasty, mastopexy or contralateral breast augmentation.

Repair Technique Selection

A thorough evaluation of the patient who will undergo breast reconstruction is required. For safe and successful reconstruction, the patient must be in a favorable medical, surgical, and psychological state. The patient’s general medical condition, family history for breast cancer, cancer treatments applied to him, height, weight, bra size, smoking, planned or expired chemotherapy or radiotherapy and surgeries that should be examined are among the subjects that should be examined. During the physical examination, the skin of the chest wall, the pectoralis major muscle, and the condition of the scars should be examined.

The most appropriate technique selection for breast reconstruction should be made by considering the following items;
Remaining chest wall skin thickness and laxity
Condition of pectoralis and serratus muscles
Condition of the contralateral breast
Evaluation of possible flap donor sites
These intrinsic factors should be evaluated and included in the operative plan to ensure consistency with the goals of the patient and surgeon.

Surgical alternatives for reconstructions after mastectomy;

1. Repair with Implant
1.1. Repair with direct implant placement
1.2. Repair with temporary tissue expander followed by permanent implant
2. Repair with Autogenous Tissue
2.1. Latissimus dorsi (LD) muscle-skin flap
2.2. Transverse rectus abdominis (TRAM) muscle-skin flap
2.2.1. pedicle transfer
2.2.2. free transfer
2.2.3. Perforator-based transfer
2.3. Free tissue transfer
2.3.1. Rubens Flap
2.3.2. Gluteal Free Flap

Breast Repair Alternatives

1. Repair with Implant
1.1. Repair with direct implant placement

In some special cases, implantable breast reconstruction without prior tissue expander may be considered as an option. However, the most important complication of this is the high risk of capsule contraction with insufficient aesthetic result. When an implant is used in immediate breast reconstruction, opening of the incision or loss of flaps or implant loss may occur as a result of infection. If the implant volume is larger than necessary, tension in the skin flaps will increase and perfusion may decrease at the wound edges. In 1984, Becker described inflatable prostheses containing silicone gel in the outer and inner lumen. In this approach, after the tissue expansion is completed, the need for permanent prosthesis placement is eliminated. Instead, the injection port and its detachable tube are removed with a simple effort. This procedure, in which the tissue expander serving as a prosthesis is left in the pocket, is a relatively minor procedure.

1.2. Repair with temporary tissue expander followed by permanent implant

After the tissue expander is placed in the mastectomy area, it is inflated for a certain period of time and replaced with a permanent prosthesis after sufficient skin coverage is obtained. Tissue expanders may be useful when the amount of skin that can be used is small or in mastectomy defects where breast volume loss is prominent. Although autogenous tissue reconstruction may provide good symmetry, tissue expansion with subsequent implant placement is a good alternative in some cases. For example, it may be an alternative for patients who do not want flap reconstruction, weak patients who do not have easily usable large tissue, elderly patients and those with other medical diseases who cannot tolerate long operation times.
The most important advantage of tissue expanders is the use of local tissues in breast reconstruction. Better color matching is achieved when compared to the opposite breast. Sensation is almost always preserved in the breast skin flaps. This technique also avoids the important donor site scars encountered in autogenous reconstruction.
In the 10-year follow-up after the placement of silicone gel implants, a rupture rate of approximately 50% has been reported. In similar studies on SF-containing implants, 1% rupture and 5-15% loss of volume in the implant were detected in a 5-year follow-up. Mechanical failure and volume loss are due to cracks on the implant. It has been observed that the fatigue phenomenon is less in subpectorally placed implants and this is due to muscle pressure protecting the implant.
Radiation exposure of the postmastectomy site is considered a relatively strong contraindication for tissue expansion. Expansion of tissue over the implant can cause relative ischemia, followed by necrosis, and implant exposure, dependent on the period of pressure on the flap. Tissue expansion should be done slowly in this case. Capsular contracture rate is high after completion of breast reconstruction

2. Repair with Autogenous Tissue
2.1. Latissimus dorsi (LD) muscle-skin flap

Latissimus dorsi muscle flap in breast reconstruction was first reported by Schneider-Hill and Muhlbauer-Oblrisch in 1977. Its use with the skin island on the muscle was popularized by Bostwick, Vasconez and Jurkiewicz in 1978. Many techniques have been described for the use of the LDM flap for breast reconstruction. Many authors aimed to raise the flap laterally with a longitudinal incision and to minimize the deformity of the back by ending it on the upper side. The elliptical skin island usually obliquely crosses the skin clump and ends on the prosthesis on the lateral side of the sternum.

After the skin island is lifted with a linear and slightly curved incision, it is placed in such a way that a good projection is obtained to form the lower half of the breast and the inframammary fold.

Although the LDM flap, largely surviving muscle tissue, durable skin island, and aesthetically acceptable results are an advantage, the high rate of capsule formation due to the prosthesis it is generally used with can be considered as a disadvantage. McCraw and Papp used the LDM flap in autologous breast reconstruction with the horizontal ellipse and fleur-de-lis pattern, using two-island planning. The advantages of the LDM flap include reliable circulation and the ability to create the desired breast geometry. It has disadvantages such as scar tissue on the back and limitation in shoulder movements, which are common after mastectomy operations.

Although the latissimus dorsi muscle usually needs to be combined with an implant in breast reconstruction, it can be used alone for the reconstruction of the muscle skin island in the form of a fleur-de-lis or in a standard ellipse, with a larger amount of muscle and fascia involved. Women who are obese and have a fatty lumbar region are better candidates for this method. However, it is difficult to shape the large breast and cosmetic deformities in the donor area should be considered.

The expanded LD flap is a modification of the standard technique. With this approach, more tissue can be obtained to form the breast mass without the need for implants. Thus, it can be considered as a good alternative in candidates who are not suitable for TRAM flaps. However, the expanded LD flap also has certain disadvantages. The most important of these is donor area morbidity. In addition to postoperative complications such as seroma, it may not eliminate the need for implants in some patients.

2.2. Transverse rectus abdominis ( TRAM ) muscle-skin flap
2.2.1. pedicle transfer

The transverse rectus abdominis musculo-skin flap (TRAM) is a useful flap for breast reconstruction. Hartampf, Scheflan, and Black described a transverse TRAM flap with an elliptical skin island in the lower abdomen by making an incision as a bilateral abdominoplasty incision. It is known that the vascular support of the TRAM flap is the deep inferior epigastric artery (DIEA), the primary source artery of the rectus muscle. The abdominal skin island is supplied by multiple myocutaneous perforators from the DIEA and the superficial inferior epigastric artery (SIEA). It is important to leave the anterior muscle sheath intact while raising the flap, to protect the capillaries that feed the muscle.

1. The primary circulation of the TRAM flap with the superior skin island is provided by the DSEA artery.
2. The middle skin island is in the center of the umbilicus. The main circulation is via the perforators from the distal DIEA. These perforators also supply the muscle through choke anastomoses from the DSEA.
3. The lower skin island is bled by DIES and is fed by the perforators in the other two flap planning.

Most vascular problems in the TRAM flap present as congestion due to venous insufficiency rather than arterial insufficiency. The arterial circulation lies on either side of the rectus abdominis muscle as two vertical vascular perforator systems. The density of perforator vessels is greatest in the periumbilical region.
Horizontal placement of the TRAM flap with contralateral pedicle is recommended. The flap should not be rotated more than 90 degrees to avoid kinking and bending of the vascular pedicle.

If the single pedicle flap is unreliable and the size and length of the single pedicle flap is insufficient, Hartramp recommends bipediculated TRAM flap application because of the high risk of flap necrosis in female patients who have been treated with cigarette smoking and chest wall radiotherapy. The bipediculated TRAM flap is also indicated when excess tissue is required. For example, bipediculated TRAM flap is indicated in cases such as supraclavicular pit, mid-down line scar and bilateral breast repair. If the bipediculated TRAM flap is to be used for reconstruction, Hartrampf usually divides the skin island into two parts and uses it in the supraclavicular and axillary pits.

The advantages of TRAM flap include breast reconstruction with the patient’s own tissue, acceptable scarring in the donor area, and performing abdominoplasty during the same operation. Disadvantages of the TRAM flap include discrepancies in the ratio of excess tissue mass and vascular support, prolonged recovery time due to abdominal complaints, and hernias caused by weakening of the abdominal wall.

Extremely obese patients, chronic smokers, those with scars on the abdominal wall, and previous radiotherapy are at high risk for complications. Autoimmune diseases, DM, chronic obstructive pulmonary diseases and heart diseases increase the chance of perioperative surgical complications. Although these factors are not a contraindication on their own, they should be carefully considered when choosing a technique (pediculated or free) for reconstruction with a TRAM flap.

2.2. Transverse rectus abdominis (TRAM) muscle-skin flap
2.2.2. free transfer

Holmstrom reported that the abdominal tissue that is normally excised in abdominoplasty operations is an important free tissue donor area that can be used in post-mastectomy breast reconstruction operations. TRAM flap is a good free flap site for breast repair since the diameter of the deep inferior epigastric artery is 2.5-3 mm, there are 2 vena comicantheses, the length of the vascular pedicle is more than 15 cm, and it covers a wide area from the midline to the anterior superior of the spina ilica.

Thoracodorsal vessels can be selected as recipient vessels for free TRAM flap anastomosis. It is important that these vessels are not damaged during mastectomy and axillary dissection. The proposed site for anastomosis is just proximal to where the thoracodorsal artery gives off the serratus branch. If thoracodorsal arteries are not present, internal mammarian vessels are the second best option. Advantages of the free TRAM flap over the pedicled TRAM flap: a. All abdominal skin zones can be reliably transferred. Because of the inferior epigastric artery, the blood supply of the flap is safer. b. There is a chance to use less muscle tissue. Thus, the remaining part of the rectus muscle can maintain its function and the incidence of abdominal hernia is reduced. c. The skin island can be planned in the lower part of the abdomen, so there is a better camouflaged scar in the donor area. 2.2. Transverse rectus abdominis (TRAM) muscle-skin flap 2.2.3. Perforator-based transfer This method was first used in breast reconstruction by Allen et al. in 1994. With these techniques, the transfer is lifted on a musculocutaneous perforator separated from the inferior epigastric artery. Flap sizes can be planned in the same dimensions as the free TRAM flap. Thus, it has important advantages such as being able to carry a large mass that can be easily shaped, leaving the muscle tissue intact and avoiding possible complications. In patient selection, there are contraindications that exist in other microsurgery patients. Since there is no muscle or fascia defect in donor area closure, no problems are encountered. Reshaping the anastomosis and flap in the recipient area is the same as repair with free TRAM, but requires advanced microsurgical experience.

2.3. Free tissue transfer
2.3.1. Rubens Flap

Breast reconstruction with the first Rubens flap was performed in 1990 (19). In Taylor’s studies, it was shown that the deep circumflex iliac artery provides blood flow not only to the iliac wing, but also to the fat and skin above it. Although Taylor described the flap dissection containing only fat and skin on this pedicle, the flap has generally been used in bone tissue repairs. Most women have enough adipose tissue in the periiliac region for breast repair. In flap dissection, unlike the classical DCIA flap dissection, bone is not included in the flap. In dissection, approximately 1-2 cm above the inguinal ligament, the external and internal oblique and a part of the transverse abdominis muscle should be included in the flap. Rubens flap planned as DCIA and vein-based may be a good alternative for breast reconstruction.

2.3. Free tissue transfer
2.3.2. Gluteal Free Flap

a. superior

The gluteal region provides greater soft tissue availability for microvascular breast repair. The original shape of the superior gluteal flap was described by LeQuang in 1979. During flap dissection, attention should be paid to the sciatic nerve and posterior cutaneous femoral nerve.

b. inferior

Although the inferior gluteal free flap is another alternative in breast repair, it is not considered the first choice. In most patients, sufficient skin and adipose tissue can be found in this area for the breast. This tissue can be preferred because of its fixed anatomical structure, structure and consistency of the adipose tissue, and good projection. In the inferior gluteal free flap, the inferior gluteal artery, which is one of the two dominant pedicles of the gluteal muscle, and the lower part of the muscle on the vein are used as musculo-skin flaps. Compared to the superior gluteal flap, the inferior pedicle may be preferred because of its longer length, more tissue use, and better donor site morbidity.

Nipple Areola Reconstruction

The final stage in almost all breast reconstructions is nipple-areola reconstruction. In the breast with an unnatural-looking nipple-areola complex, the reconstruction cannot be considered complete and consists only of a breast mass. Generally, nipple-areola reconstruction is performed in second-stage surgery, where both breasts reach an acceptable symmetry. This surgery is a procedure performed under local anesthesia or without anesthesia. If a composite graft is to be used in nipple-areola reconstruction, the only graft source is the contralateral nipple. Local flap should be the choice in nipple reconstruction. When the appropriate technique is chosen, a nearly identical reconstruction of the contralateral breast is achieved, with minimal donor site morbidity and distortion. The position of the nipple-areola complex is very important. For this, various measurements must be made. The best way is to measure the transverse midsternal line and the nipple distance and the sternal notch-nipple distances. Many methods can be used in nipple reconstruction that allow donor area closure without the need for a graft. However, in cases requiring large nipples, local flaps and grafts can be used together. One of the treatment choices in areola reconstruction is tattooing. Generally, it is more appropriate to do it 4 weeks after nipple reconstruction.