Every patient is unique, and there is no universal approach or design that works for all women regarding breast reconstruction. Women's breasts vary in size, shape, position, and skin tightness, leading to different considerations for each case. Several factors influence the reconstruction process, such as the cancer's location within the breast, its depth relative to the overlying skin, and its relationship to the nipple-areola complex. Additionally, the degree of breast sagging and the amount of excess skin present, as well as the thickness or thinness of the skin, all play critical roles in determining the most suitable reconstruction options for each individual patient.
A preoperative MRI is a valuable tool for diagnosing the location of cancer within the breast. It also aids in assessing skin thickness and the predominant blood supply to the breast, information essential for both the oncologic and reconstructive surgeons. It is crucial to closely evaluate the blood supply, particularly between the second and third intercostal spaces, to ensure that the cancer surgeon can safely preserve this blood supply without compromising cancer removal. Questions regarding the thickness of the skin and other factors are addressed during the preoperative phase, guiding the design of mastectomy incisions and informing the reconstruction process.
The removal of the nipple-areola complex is a controversial decision that ultimately rests with the oncologic surgeon. Recent studies suggest that skin-sparing mastectomies can be oncologically safe for certain tumors, particularly if the tumors are at least 2 cm away from the nipple-areola area, and do not increase the risk of recurrence. However, if the nipple appears flat and lacks color, preserving it may not be beneficial, as nipple-areola reconstruction could yield a more aesthetically pleasing result. Conversely, if the nipple is projected and the areola has a well-defined, appropriate diameter, preserving it can provide a more natural appearance. In cases where the nipple-areola complex must be excised, careful surgical planning can lead to superior cosmetic outcomes.