The loss or deformation of breast caused by the treatment of malign tumor touches the woman in two areas. Beside the fear of further destiny, treatment and state of health, women suffer from the fear from how will their life change after a loss of such a big womanhood symbol.
Its proof is also that during the first information about the character of the disease and the planned treatment, a big percentage of women react in more positive way, when they find out together with the information of the necessity of breast removal about the possibility of its reconstruction.
The care of women with malign tumor is inter-branched and it presents cooperation of mammogram specialist, surgeon, oncologist, radiodiagnosis specialist, pathologist, gynecologist and also psychologist. Breast reconstruction is part of the plastic surgery. The decision whether and when to perform the surgery depends on the oncologist, psychologist and sometimes even the geneticist.
Surgical methods of breast tumor treatment
Reconstruction possibilities depend on the extent of surgically removed tissue.
Radical mastectomy (removal of breast tissue): The entire breast is removed including skin above it.
Breast tissue-sparing mastectomy: The tumor is removed with sufficient surrounding tissue. The breast is preserved in the most satisfactory shape. After that it is possible to modify it.
Skin-sparing mastectomy: The mammary gland is removed together with nipple and areola. The skin remains though.
Subcutaneous mastectomy (removal of breast tissue): During this surgery the surgeon removes the entire mammary gland but the skin, nipple and areola is preserved for the case of further reconstruction.
Are you a suitable candidate for breast reconstruction?
The patient after breast removal cannot undergo breast reconstruction. In this case she wears in the bra so-called epithesis (it is an imitation of breast which is custom-made). Epithesis is not fixed to the body. The woman herself decides whether to undergo the reconstruction surgery. It is important for the patient to be psychically stable in her decisions. She should realistically evaluate the possibilities of plastic surgery. It is essential that she realizes that the newly formed breast will never exactly replace her natural breast. It is also necessary to count with scars and often even in the area outside of breast (for example in the area of back or abdomen). From the health point of view the patient should not have diabetes, vascular diseases of heart diseases. Another health risk that could threaten the result of the reconstruction is patient’s obesity. Also smoking can complicate the reconstruction, so it will be recommended to the patient to quit, which is also because of oncology disease more than desirable. If the patient’s health and psychic state allows to undergo the reconstruction, she should have report from her oncologist and radiologist about termination of treatment.
The timing of the surgery
One of the possible options is so-called immediate breast reconstruction. It is the case when during one anesthesia the surgeon removes the tumor with a part or with the whole breast and he/she then immediately fills the formed defect. Most often this procedure is applied in so-called prophylactic surgeries. Those are procedures in which potentially dangerous tissues are removed. In such breasts most often subcutaneous mastectomy is performed. In this procedure only the mammary gland is removed and the skin and areola with the nipple retains. The reconstruction is then usually performed with the usage of silicone implants. By immediate reconstruction we can also use as an advantage skin-spared mastectomy. In these cases woman avoids psychic stress from the loss of breast.
Another possibility is so-called delayed breast reconstruction. It is a situation when the reconstruction procedure is performed after the termination of all examination concerning the recognition of the state and character of the breast tumor, thus in weeks to months. Those are cases, when it is not necessary to follow the surgical procedure with oncological treatment and it is performed rarely.
Breast reconstruction is most often undertaken after the end of oncological treatment and the negative examination aimed for possible secondary spread of tumor. It is usually performed after more than one year after the primary procedure.
The procedure of breast reconstruction
Breast reconstruction is performed in several phases. At first skin and breast tissue is replaced and the breasts are modified to be symmetric. In the second phase breast areola is shaped, the third stage deals with nipple reconstruction. The aim is to form natural and symmetric breasts.
In principal there are 3 options of breast reconstruction. Always it involves gaining of the tissue volume in the place of missing breast.
The usage of own material (transfer of the skin, sub-dermis and possibly the muscle to the place of missing breast)
The usage of synthetic material (silicone implant, saline-filled implant or implant combining silicone content with saline)
The combination of own material with the implant (when there is used the transfer of the skin and sub-dermis from the near area of missing breast and the following filling with the implant)
The use of own material
By this method we use muscle flaps from surrounding or further places. The surgery is performed under general anesthesia and takes approximately 2-6 hours depending on the used flap.
Most often used is so-called TRAM flap (Transverse Rectus Abdominis Musculocutaneous flap). It is a tissue that is transplanted from the woman’s lower abdomen. The major part consists of subcutaneous fat covered with skin. The result is an arcuate scar in the lower abdomen, the same as in cosmetic abdominoplasties.
It is possible to transfer this tissue to the area of the missing breast in several ways:
Abdominal pedicle flap (pedicle TRAM flap)
With the application of one of the muscles that forms the abdominal wall. It is the oldest method used for breast reconstruction. It brings the need to solve the formed defect of abdominal wall to prevent the creation of hernia. That is why this part of the body is often covered with small net as in solving bigger hernia.
It is possible to perform this procedure in all clinics of plastic surgery where the breast reconstruction is performed. The main disadvantage of this method consists in the separation of 60-100% of the rectus abdominis muscle on one or in worse case on both sides. It causes great weakness of the abdominal wall.
Free abdominal flap (free Tram flap)
The tissue is totally separated from the vessels and transplanted it to the desired area. After that it is necessary to reconnect the vessels of the flap to the blood supply.
In this case the suturing of the vessels is made under the microscope. That is the reason why such surgeries can be performed just at the plastic clinics where microsurgical procedures are made.
The advantage of this procedure is that the defect in the abdominal muscles is not big or with the usage of so-called DIEP (Deep Inferior Epigastric Perforator Flap) flap no defect is created. Thanks to high level of microsurgical technique free TRAM lap is nowadays better equipped with vascular supply than pedicle flap. Microsurgical surgery is time-consuming and therefore in case of both-sided reconstruction we choose rather another method. Also care after the surgery is more strenuous than by pedicle TRAM flap.
The disadvantage is in principal longer process of the surgery and more strenuous care after the surgery.
Second area that is with great advantages used for breast tissue replacement is a part of large back muscle. It is turned together with the skin on the front side of chest. The advantage is in transport of the tissue without damaging the microcirculation. The tissue of the large back muscle is suitable to creation of small breast.
For transplantation of needed volume of the tissue it is possible to use also other parts, although they are applied much less. Those are mainly buttock muscles, tensor muscle of large fascia.
The advantages of the usage of own material:
It is not a foreign material
The psychological moment
Lesser risk in the irradiated terrain
The correction of the second breast is not always needed
Final cosmetic look of the donor place
Abdominal flap provides skin and fat even for reconstruction of large breasts
The disadvantages of the own material:
Longer surgical procedure
The possibility of defect creation in the donor place, abdominal hernia, problems with body posture and back pain
More strenuous care after the surgery
The use of synthetic material
In very small breasts it is possible to perform breast reconstruction directly by inserting an implant to the area. This technique is used in subcutaneous, skin-spared or breast tissue-spared procedures.
In bigger breasts it is possible to insert a special type of implant to the reconstructed place, so-called expander (imagine it as a silicone bag with filling valve) that is after the surgery gradually filled through skin by injection to the desired size (about 200ml more than planned implant). The filling takes about 1 - 2 weeks and there is inserted 50 - 100 ml of the gel or saline into the expander during one filling. The total time needed for the filling of expander is 5-6 days. During that the skin above the expander is “stretched”. Like this we achieve to get enough tissue with which we can subsequently cover the implant of needed size. In the period of 1 - 5 months after we achieve the final size of expander, we replace the expander with silicone implant or we leave the existing filled implant, which represents permanent solution.
After that we can either leave the existing filled implant or we can change it with silicone filled implant.
It is not necessary to transfer skin flap.
The method is advantageous in patients with undamaged skin after radiotherapy (after radiotherapy the skin might be gentle).
In case of reoperation we can use any other method (e.g. thoracodorsal flap).
High price of the expander.
The need to come for infusion adding the expander.
The danger of spontaneous leakage of the expander.
Last option in this group of reconstructions is the usage of so-called Becker implant. In principle it is an implant with two cells. One is filled with silicone and the other one is added to its desired size with saline. We can therefore call it expander-implant.
The combination of own and synthetic materials
During this procedure the excess of skin coverage, which is needed to cover the inserted implant, is transferred from the skin of near area. Most often so-called thoracodorsal flap is applied, when the skin from the surrounding side is transferred to the area of newly reconstructed breast.
Another, shorter time used method, is the transplantation of the skin from the adjacent area of abdomen, so-called abdominal flap. The advantage of this method is that no other scar is created during the surgery because the procedure is performed from the scar after the breast ablation. The surgery is performed under general anesthesia and t takes 2 - 5 hours.
The advantages of the use of synthetic material:
Shorter surgical procedure
Less strenuous care after the surgery
Suitable for small breasts and skinny women
No functional defect of abdominal wall
The disadvantages of synthetic material:
The psychological moment in the usage of foreign material
Problematic application in irradiated terrain
The complications during the healing of the implant (the capsular contracture)
The need to correct the other side in bigger breasts
Breast tissue-sparing reconstruction
This method is nowadays used still more often. It is given by a principal, which is used by so-called prophylactic mastectomy. This term is used for removal of breast tissue in women that have breast carcinom in family’s anamnesis and their finding on mammogram is uncertain (x-rays breast examination). Reconstruction techniques that follow use classic mastopexy (breast modeling). Often both sided breast surgery is necessary to reach the symmetry. You can find more about these procedures (Breast Modification, Breast Lift, Mastopexy).
Further phase of the breast reconstruction
In other phases we deal with the change of symmetry of contralateral breast tissue. Next follows reconstruction of areola and nipple, if these structures were not preserved during the mastectomy.
This topic has been already described in another article. At the same time, an additional change of size and shape of the other breast might be made (breast modeling).
In interval of several months (1 - 3) a new nipple and areola is reconstructed.
Transfer of a part of areola from the other breast
Transfer of skin implant from upper inner side of thigh
In today’s reconstruction surgery we make symmetric and color identical nipples. Erectile function can not be replaced yet, although well performed surgery helps women to regain their self-confidence.
The replacement of areola complex can be made by non-surgical method (tattoos and prosthetics) or surgically. We can often combine tattoos with surgical solution, when the color of transplanted tissue is modified in patients. We can use tattooing also without reconstruction, the areola complex is then quite unnatural though. The pigment is very stable, although sometimes it can darken or change the color tone otherwise. Due to changes in color the tattoo has to be repeated. Prosthetic replacements are nowadays not much used anymore.
For surgical reconstruction of breast areola there are used skin grafts from the other areola or from inner side of thigh. It is possible to use skin graft from any place even from the scar after mastectomy, in this case we cannot avoid coloring with the use of tattoo. Nipple reconstruction is more complicated. The surgeon must shape nipple, which is symmetric in size and same in color. Final phase of the reconstruction is performed approximately in
3 months after the breast tissue reconstruction. It is important to have the breast tissue healed and stable in shape. In case of only one sided nipple complex reconstruction the surgeon tries to make symmetric reconstruction. If it is both sided reconstruction the surgeon chooses shape, size and placement of breast areolas according to norms. The areola is in the distance of 10 - 12 cm from the center of chest and approximately 20 - 22 cm from the neck hole. Average areola is 40x40 mm.
Graft from contralateral nipple
The best structural and colored combination is reached when we use the skin graft from contralateral nipple. Condition for that is sufficient size of contralateral nipple. In average it should not be smaller than 5 cm. There are several ways how to lead the incision lines. Most frequent is so-called ring transplant, during this reconstruction we cut concentric circle from the healthy side. The outer part of the circle is transferred on the opposite side. There is also the possibility to use spiral transplant, although this method is not so common anymore because of unaesthetic spiral scars.
Graft from the area of inner thighs
Skin graft from the area of groins, inner side of thighs and from the area of labia is after its transplantation also colored. It is not exceptional to add the reconstruction of contralateral or transplanted nipple with the help of tattoos.
Another method is the use of so-called AloDerm, which is replacement of skin or placement of cartilage in the subcutis to form nipple. This surgery is very creative but often without satisfactory result. The client must undergo reoperations that bring the satisfactory effect.
The surgery can be performed under local anesthesia.
Transfer of part of breast nipple from the other breast
Reconstruction with local flaps
Reconstruction with the help of graft from contralateral side
The donor nipples must be sufficiently big by the use of graft from contralateral side. The surgeon cuts enough big wedge (nipple wedge reconstruction) so that both final nipples look symmetric. Similar effect might be achieved by amputation of the tip of nipple. It is then transplanted on the contralateral side.
Reconstruction with the help of local skin flaps
During this method we use many ways how to form nipple. For example star flap, flap in the U-shape, S flap, CV flap, skate flap, central flap.
The care of the patients with reconstructed breast is long-lasting and minimally the follow-up of the treated patient is for the whole life. In spite that, the breast reconstruction brings higher self-confidence and according to what they say, it improves significantly the quality of their private life and very often even the professional life.
Care after the surgery
If the patient undergoes replacement of autologous tissues or combination of autologous and synthetic material it is necessary to stay 1 - 3 weeks in the hospital. After 2 - 4 weeks it is possible to have normal daily program and rehabilitation. Physical strain and exercise is recommended after 3 months, it depends on the speed of healing. The area of reconstructed nipple is very likely to infect after the surgery. Therefore we cover the whole area with antibiotic ointments. We also protect the nipple with classic tip for better breastfeeding or with special cover that will be recommended to us at the clinic. Not only in the post-surgical period but also during the rest of life the patient should care about right lifestyle and quit smoking. The main reason why to stop smoking is worse blood supply in smokers and therefore even more frequent necrosis of transplants that are very sensitive to blood supply.
Results and their duration
The durability of the tattooing is not very long but the areola can be again colored. The final effect of the areola-nipple complex reconstruction is very individual. It depends on the life style, the moves of the tissue by healing process and changes of healing scar. The effect is permanent if the patient with good lifestyle is satisfied with the reconstruction and precedes complications.
The patient before next phase of nipple and areola reconstruction
Women that undergo the reconstruction are after breast ablation due to carcinoma and the plastic surgeons, oncologists and gynecologists fear another eruption of the disease. The patients should not fear because the reconstruction does not hinder screening check-ups. Also more frequent carcinoma relapse has never been proved. Surgeons also fear worse blood supply of the tissues and following necrosis. Like every surgery also this one is associated with infection and bleeding complications. In case of combination of own tissue and implant there is a small risk of prolapse of the implant between the muscle bundles. Very rare complication is so-called capsular contracture. It is a situation when the reconstructed breast heals but during the healing process it gets firm and there form firm ligamentous capsule around the implant. Undesirable are also changes in shape and shifts of implants.
After breast removal due to tumor disease is its reconstruction covered by health insurance.