**3. Mastectomy and breast reconstruction**

Simple mastectomy is a good surgical option for elderly patients, women living in remote areas with limited access to radiotherapy and those who do not wish to undergo immediate reconstruction (**Figure 18**). Increasing number of women is choosing to have mastectomy with immediate reconstruction instead of breast conservation [16].

'A good reconstruction starts with a good mastectomy' is an often quoted by oncoplastic breast surgeons and advocated by the Nottingham Breast Unit, UK. Historically, free-transverse rectus abdominis (TRAM) flap or deep inferior epigastric artery perforator (DIEP) flap has been regarded as the gold standard for breast reconstruction [17]. This is a significant undertaking for patients with prolonged hospital stay, delayed recovery and donor site morbidity. Not surprisingly, the incidence of these complex autologous flaps has remained static compared to the exponential increase in implant reconstruction over the past three decades [18].

Latissimus dorsi (LD) flap with implant (**Figure 19**) was a common reconstruction procedure post mastectomy in the 1980s and 1990s, due to the robust nature of the flap, consistent aesthetic results and acceptable donor site morbidity compared to TRAM flap. The incidence of LD has declined with the increasing incidence of implant reconstruction in the late 1990s and early 2000s. More recently, there appears to be a resurgence of LD flaps, according to MD Anderson data [18].

**Figure 18.** Right simple mastectomy.

The chest wall perforator flaps (L-TAP and Li-CAP) can also be used as complete autologous flap reconstruction following mastectomy and was first described by Losken and Hamdi in 2009 [19, 20]. This is a safe reconstruction option in the high-risk candidates, such as smokers, raised BMI, diabetics, or in patients where implant or complex autologous reconstructions are relatively contraindicated due to post-operative radiotherapy (**Figures 20** and **21**).

anticipated, patients could be offered re-excision of margins or conversion to mastectomy. A two-stage procedure helps avoid wasting a good flap in the initial stage and serves as a bridge

Simple mastectomy is a good surgical option for elderly patients, women living in remote areas with limited access to radiotherapy and those who do not wish to undergo immediate reconstruction (**Figure 18**). Increasing number of women is choosing to have mastectomy

'A good reconstruction starts with a good mastectomy' is an often quoted by oncoplastic breast surgeons and advocated by the Nottingham Breast Unit, UK. Historically, free-transverse rectus abdominis (TRAM) flap or deep inferior epigastric artery perforator (DIEP) flap has been regarded as the gold standard for breast reconstruction [17]. This is a significant undertaking for patients with prolonged hospital stay, delayed recovery and donor site morbidity. Not surprisingly, the incidence of these complex autologous flaps has remained static compared

Latissimus dorsi (LD) flap with implant (**Figure 19**) was a common reconstruction procedure post mastectomy in the 1980s and 1990s, due to the robust nature of the flap, consistent aesthetic results and acceptable donor site morbidity compared to TRAM flap. The incidence of LD has declined with the increasing incidence of implant reconstruction in the late 1990s and early 2000s. More recently, there appears to be a resurgence of LD flaps, according to MD

to the exponential increase in implant reconstruction over the past three decades [18].

to definitive surgery.

20 Breast Cancer and Surgery

Anderson data [18].

**Figure 18.** Right simple mastectomy.

**3. Mastectomy and breast reconstruction**

with immediate reconstruction instead of breast conservation [16].

**Figure 19.** Right mastectomy with immediate LD flap and left mastectomy with implant reconstruction.

**Figure 20.** Pre-op marking bilateral mastectomy following neoadjuvant chemotherapy.

**Figure 21.** Post-op bilateral skin-sparing mastectomy with immediate Li-CAP flap reconstruction.
