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The term "breast reconstruction" describes the plastic restoration of an amputated female breast. With the help of the body's own tissue or an artificial implant, the original breast shape, including the nipple, is modeled.
Breast cancer and the removal of the diseased breast are the main reasons for a breast reconstruction. But also congenital malformations or the precautionary removal of the mammary gland at a genetically increased breast cancer risk may be reason for a breast reconstruction.
DIEP, TRAM, S-GAP, I-GAP, implant - the list of methods for breast reconstruction is long and often confusing for laymen. Every procedure has its advantages and unfortunately also disadvantages.
In principle, a breast reconstruction can be performed at any time - either in combination with mastectomy (primary reconstruction, one-step procedure) or as a separate procedure at a later time (secondary reconstruction, two-stage procedure). Primary reconstruction (immediately after amputation) is less of a mental burden for some women.
Other patients, on the other hand, first want to recover from mastectomy and calmly deal with the various options of plastic surgery before undergoing breast augmentation. An additional influence on the optimal time for breast augmentation also plays a role in further treatment planning, ie whether, for example, radiation is planned after the amputation.
Women with mammary gland cancer have to deal with two problems simultaneously: they don’t only fight against the fatal disease. Pretty often, they’re under risk of losing one or two breast, which affects their female essence. When breast cancer is finally defeated, breast reconstruction (reconstruction of mammary glands) can become the next step to full recovery.
Restoration of mammary gland removed during treatment of breast cancer can be performed either with the help of patient’s own tissues (skin, fat, muscles), or with implants. Breast reconstruction is a fast and natural alternative to wearing a movable breast prosthesis. It helps many women to restore normal life after breast cancer treatment.
Who is a good candidate for breast reconstruction?
Patient’s overall health plays crucial role when a doctor decides whether the operation can be performed. It’s even more important in such case rather when a woman did not experience any conditions before.
All risks to patient’s health should be drawn to the zero. This operation is prohibited for women with diabetes, vessel and heart diseases. Smoking can also lead to complications, therefore, patients are strongly recommended to break this habit. Besides, smoking increases the risk of cancer development dramatically.
Women considering breast reconstruction should know that the reconstructed breast cannot fully replace natural one, and it won’t be totally identical from the visual standpoint, as well. The main condition of successful breast reconstruction is cooperation with doctors and following to their recommendations. In most cases, post-surgery care is performed in so called breast treatment center.
Since every case is individual, every patient should discuss the possibility of breast reconstruction with her oncologist.
Techniques and procedures of breast reconstruction
There are two basic variants of breast reconstruction operations. Reconstruction can be performed together with tumor removal. If a preventive operation is made (so called “immediate breast reconstruction”), reconstruction usually implies using silicone gel implants.
Another option is a delayed breast reconstruction. It is usually performed several weeks or months after all oncologic procedures are made. This operation is performed rarely.
The right time for breast reconstruction also depends on whether ray therapy is required.
Method of breast reconstruction is figures out individually and depends on clinical performance. As a rule, breast reconstruction is made in three stages: first, skin and mammary gland tissues are replaced, then symmetry of both breasts is restored. Then areola is formed. Finally, nipples are reconstructed.
Breast reconstruction can be performed either with patient’s own tissues, or with artificial materials (most often, silicone implants). Less often, both approaches are combined together. Use of implants may require skin stretching so that the implant could be placed under skin.
When patient’s own tissues are used, the material is obtained from other body parts (as a rule, fro, abdominal area). The main drawback of this procedure is that it’s long-lasting, and leaves scars on other body parts. A determinative factor (and a psychologically valuable one) for the operation is the fact that no foreign objects are used for it.
Patient’s own tissue
In case of breast reconstruction with patient’s own tissue, skin, fat and muscles are moved or transplanted from one body part to another. The main benefit of this method is that a woman feels more comfortable, when there are no foreign objects in her body, and it also allows creating big and plump breast. However, even when this method is used, sensitivity still will be lost.
In places where replacement tissues were obtained, big and visible scars can stay. They can also lose muscle functioning and collect tissue secretion.
The most frequently used methods
LADO (Latissimus Dorsi, the widest spine muscle) flap: spine muscle Latissimus dorsi is used as a donor tissue, this skin-muscle flap is stretched under the armpit and helps to form the new breast. Blood flow is not obstructed in this case.
TRAM (Transverse Rectus Abdominal Muscle) flap and DIEP (Deep Epigastric Artery) flap are used. These are anatomical areas in the lower part of abdomen that can be used as skin-muscle flaps to be freely transplanted (blood flow will be successfully restored with the help of minor blood vessel after formation of breast). Alternatively, blood flow can be restored by connecting the area with the most important artery located under abdominal skin.
S-GAP (Superior Gluteal Artery Perforator) flap and I-GAP (Inferior Gluteal Artery Perforator) flap. Skin and adipose tissue is taken from the upper or lower butt part. This is a good alternative for skinny patients who don’t have enough skin on the abdomen.
TMG (Transverse Musculocutaneous Gracilis) method of transplantation allows transplanting skin, fat and hip muscles. It’s suitable for patients with small breast and excessive tissue on the inner side of the hip.
Nipple restoration: division and transplantation of healthy nipples, local flap plastics (flaps are taken from breast skin), skin flaps from pigmented body parts and imitation with tattoos.
Modern implants are filled either with silicone gel or physiological solution, and are covered with silicone layer. If a patient has enough skin left after mammary gland removal, prosthesis can be placed without additional procedures. Otherwise, doctors place special plastic bags under skin called “expanders”. Within several weeks, it is gradually filled with fluid to stretch skin normally.
Prosthesis with expander
Combination of breast expander and permanent breast implant doesn’t’t require additional operations, and is suitable for immediate reconstruction right after breast removal.
Operations for breast reconstruction with patient’s own tissue are more hard and complicated than installation of silicone prosthesis, though cosmetic results after such operation are usually better. On the other hand, breast reconstruction with silicone implants requires a short operation (1-2 hours) and doesn’t cause any functional restrictions and additional scars.
To make both sides look symmetrically, additional correction of breast form and shape can be required. As a rule, surgeons diminish the size of the big breast and lift it so that to make the difference between both breasts less noticeable.
To reconstruct nipples, doctors usually apply tattooing and skin flap transplantation (local flap plastics). Another method implies using the tissue from the healthy nipple: some part of a healthy nipple is removed and transplanted on the second breast. However, this method is suitable for women with very big nipples only.
To restore nipple areola, patient’s own skin can be transplanted, or it can be imitated with the help of tattooing. Nipple reconstruction is performed only after successful finishing of all the preceding stages. It’s important to wait until the reconstructed breast recovers and gets its final shape.
Risks and possible complications after breast reconstruction
Patient’s biggest fear is to develop cancer recurrence. Therefore, it’s important to let patients know that after breast reconstruction, they should go through mammary gland cancer screening, but it causes no risk of cancer recurrence.
General surgical risks
Just like any other operation, breast reconstruction poses some general surgical risks, such as bleeding, infection and poor curing of wounds. However, with high standards of hygiene and quality, these risks are minimal. Today, patients can normally bear general anesthesia. An anesthesiologist perfectly controls patient’s state during operations.
Specific risks during breast reconstruction
Tissue fibrosis (local hardening of breast) can happen during breast reconstruction with implants. The risk of tissue fibrosis is especially high, when mammary gland cancer was treated with ray therapy. In this case, breast implants are not recommended for breast reconstruction. In this case, the best variant is breast reconstruction with patient’s own tissue.
If chemotherapy and ray therapy were applied after tumor removal, breast reconstruction is not recommended to be done until the skin totally heals and regenerated. Ray therapy affects blood flow in skin, which takes its toll on wound recovery after breast operations.
If breast reconstruction with patient’s own tissue was performed, negative outcomes can take place depending on the zone where the healthy tissue was obtained from. For example, spine movement can be restricted (when the flap was obtained from latissimus dorsi), sensitivity can be lost, or abdominal wall can weaken (when TRAM flap was used).
Besides, there’s a risk that the result won’t be aesthetic enough, and there can be asymmetry (sometimes it happens after other aesthetic surgeries, for instance, when breast was augmented with patient’s fat tissue). However, the vast majority of patients claim they experience better quality of life after successful breast reconstruction.
How to find a good surgeon for breast reconstruction?
Plastic surgeons specializing on breast reconstruction should treat their patients attentively and have the sense of delicacy. Women going through breast reconstruction experience a lot of hopes and worries during this period, and they expect to restore normal life after surgical treatment. A doctor should explain all possibilities of breast reconstruction and tell patients what cannot be achieved with such procedure.
Patients considering this procedure should pay primary attention to the doctors who specialize exactly on breast reconstruction, because this operation requires high professional competence and rich experience. Such specialists typically work in “breast treatment or mammary centers” that usually comprise bigger clinic. However, there are also separate specialized breast centers. It’s recommended to choose doctors who focus on “restorative surgery” or “plastic surgery”.
Doctor’s experience in the sphere of mammary gland reconstruction is more important. When choosing a doctor, it’s important to consider help of surgeons who have already performed a large number of such operations during several years. The quantity of operations matter a lot, and their results should be proved with medical certificated and photographs showing the results before and after.