This technique can be used in any case of breast tissue removal that cannot be successfully replaced by a simple remodeling of the glandular shape. Based on the quadrantectomy specimen size and weight, the free dermal fat graft site is drawn on the inferior abdominal wall. Different from the traditional Kijiama technique [1], which excises abundant suprapubic tissue to design it on the breast defect site and consequently wastes some tissue, in our setting a tissue lozenge is excised with a major and a minor diameter and is cut into two parts to duplicate its minor diameter. In accordance with Kijiama, we observed that graft size is maintained with the passage of time, so sizing it using dimensions larger than the actual measurements is not required[2].

Suprapubic tissue is then transferred within any breast defect on an adequate receiving bed, i.e., the pectoralis muscle. In particular, a suprapubic area is initially disepithelizated with the accurate preservation of derma vascularization, which is very important for its consequent engraftment. Then, the graft is excised by cold scalpel with a maximal thickness of 2-5 cm, cut, and sutured as previously described, weighed, and finally transferred within the receiving breast area. The graft dermal side is sutured to the pectoralis muscle surface using separate absorbable stitches 3/0 (Fig. 8.2).

Before wound closure, drainage is placed in the graft site, which is maintained in aspiration modality for approximately 24-48 h. Medication of the donor and the receiving areas are performed respectively with mild compression and plate dressing.

Implant-based reconstruction represents the most common reconstructive technique after mastectomy. The choice of temporary expanders or definitive implants depends primarily on the quantity of residual skin after surgery and consequently on the type of mastectomy. In particular, definitive prosthesis may be used after nipple-sparing mastectomies or skin-sparing mastectomies accompanied by eventual contralateral skin-reducing mastoplasty, whereas tissue expanders may be indicated after modified total mastectomies of after skin-sparing mastectomies without sufficient residual volume for the definitive implant.

Skin-sparing mastectomy is performed in case of multicentric, extensive, or recurrent lesions and early-stage breast cancer for which breast-conserving therapy results are not suitable, by removing the breast (breast parenchyma and nipple-areola complex), the lining over the pectoralis major, and the biopsy scar but sparing breast skin and the pectoralis major muscle. Skin involvement by the tumor was considered an absolute contraindication. Selection criteria for nipple-sparing mastectomy include no gross clinical, radiographic, or pathologic involvement of the nipple-areola complex, a peripheral cancer location in the breast parenchyma (distance from the nipple-areola complex ≥1 cm), and a clinically negative axilla. And nipple-sparing mastectomy is performed as skin sparing mastectomy but skin incision is inframammary and the nipple- areola complex is conserved.

In case of nipple-sparing mastectomy , the subcutaneous dissection under the areola is aimed at removing the glandular and ductal tissue without compromising the vascularization of the nipple-areola complex (Figs. 8.3, 8.4, and 8.5). In case of positive histology by routine intraoperative frozen section of ducts beneath the areola, the nipple- areola complex is removed before proceeding to wound closure. In addition, the breast surgeon could decide to remove the NAC before radiotherapy in case of high risk for NAC necrosis because of poor blood supply.

Reconstruction of the breast with tissue expanders can be performed either immediately at the time of mastectomy or in a delayed modality in a minimum of two stages (Figs. 8.6 and 8.7). Placement of a tissue expander immediately after mastectomy allows the preservation of the overlying skin and the avoidance of the scarring and contracture of the skin that usually occurs when reconstruction is delayed. Conversely, immediate breast reconstruction is burdened by higher risk of skin flap necrosis, hematoma, and infection [3, 4].

The only absolute contraindications for implant-based breast reconstruction are local infections or an insufficient amount of skin to cover the tissue expander after mastectomy. Relative contraindications include previous breast radiation therapy, high quantity of tobacco smoke in patients who are candidates for two-staged reconstruction, and obesity [5–10].

Tissue expander is placed in a submuscular pocket under pectoralis major muscle. Although some plastic surgeons still advocate placement of the expander only partially in the submuscular position under the pectoralis major, leaving the inferior portion subcutaneous, the complete muscle coverage provides the most protection to the prosthesis in the event of mastectomy skin flap necrosis. In the case of incomplete coverage of the inferolateral portion of the expander, due to individual muscle characteristics or to partial muscle resection for oncological reasons, acellular dermal matrix has been recently introduced, which provides total coverage of the expander with less pain by avoiding dissection of the serratus and rectus fascia [11, 12].

The availability of skin after mastectomy and the size of the muscle pocket limit the volume of intraoperatively injected fluid into the tissue expander. Obviously, the creation of a larger pocket reduces the number of postoperative tissue expansions with a consequent shortening of the whole reconstructive process.

The two-stage approach implies a serial postoperative expansion of the implant with 60-150 cc at a time or as tolerated by the patient until the desired volume is reached. After 1-6 months of maintenance of the desired volume, it is possible to proceed to the next stage, when the tissue expander is exchanged with the permanent implant. In this occasion, it is possible to perform capsulotomy and reshaping of the breast pocket to correct minor asymmetries and to enhance the texture and appearance of the reconstructed breast. When the anesthesiologic risk exceeds the benefits of the two-stage technique, for example in older women or those with many comorbidities, immediate implant placement is preferable, eventually using acellular dermal matrix (Fig. 8.4) but does not guarantee natural shape and appearance. A third stage may be sometimes required, for example, for the nipple reconstruction or nipple repositioning (Fig. 8.8).

Taking into consideration the adjuvant therapies, tissue expansion should be ideally performed during chemotherapy course, and its exchange within a permanent prosthesis should be ultimate before radiation therapy initiation. This delicate argument will be debated in the next sections.

Finally, it is important to remember the impact of implant-based reconstruction on breast cancer detection. Mammography results not indicated for breasts reconstructed with prosthesis, so that follow-up is made by regular ultrasound examination. In case of difficult imaging interpretation, magnetic resonance imaging may be very useful to exclude disease recurrences.

This kind of reconstruction is based on the use of autologous tissue, including myocutaneous flaps, fat dermal grafts (already discussed in a previous section), and simple fat grafts (lipofilling, which will be discussed in a following section).

Myocutaneous flaps have been almost completely replaced by prosthesis reconstruction, which surely implies a simpler and shorter operation. On the other hand, myocutaneous flaps do not require a two-stage surgery, and the aesthetic outcome of autologous reconstruction results obviously better than that of prosthetic surgery. In particular, autologous tissue follows the changes of the whole body, so that if the patient increases or decreases in weight, she does not lose the symmetry of her breasts, which usually seem more natural over the time.