Breast reconstruction

MASTECTOMY AND BREAST RECONSTRUCTION (ONCOPLASTIC SURGERY OF THE BREAST)

1. Introduction

Breast cancer is the malignant tumor more frequent and affects 10% of women in the western countries. The main therapeutic option is the surgical treatment, either mastectomy or conservative surgery. Any of these treatment produces important asymmetries.

Nowadays only 15-30% of women undertake breast reconstruction. This procedure intends restoring the symmetry, creating a new breast with similar features in shape, size, contour and position to the contralateral breast, correcting the anatomic defect.

A mastectomized woman is not definitely healed until the breast has been reconstructed. There are hundreds of studies that show that breast reconstruction is very important for the psychical recovery of the patient and for their self-esteem.

Breast reconstruction is safe and does not delay adjuvant treatment nor prevents the diagnosis of a recurrence.

Breast reconstruction can be immediate or delayed. We can use silicone implants or the own tissues or combining both techniques.

2. Immediate vs delayed reconstruction

The reconstruction can be performed just at the moment of the mastectomy or after the adjuvant treatment is finished.

Immediate reconstruction

The main advantages are lesser costs, superior aesthetic outcomes and less psychologic impact on the patients. However it is not indicated in all patients. It is a very good option for early stages (I-II). In more advanced disease it is better to perform a delay reconstruction, although it is not an absolute contraindication for an immediate procedure. Immediate reconstruction is not indicated in women that are overwhelmed with the disease and the therapies and in patients that need postoperative radiotherapy. Finally the team has to be familiar with the procedures involved in immediate reconstruction.

Delayed reconstruction

This is performed at any time once the wound has healed and the adjuvant therapies have been finished. . The main advantages for delayed reconstruction are that the surgeon is not worried about if radiotherapy will needed or not and if it will affect to the result. The surgeon can choose the best reconstructive option; secondly, it seems that there are fewer complications in delayed tan in immediate reconstruction. Disadvantages of delayed reconstruction are lengthening of the total time for the treatment, worse aesthetic results and higher costs.

3. Reconstructive techniques

3.1. Tissue expansion + implants

This technique encompasses two operations. The first one is for placement of the expander, which can be immediate to the mastectomy or delayed.
Once the wounds have healed the expander is inflated once every week. Around 3-6 months after placement of the expander this is taken over by a definitive cohesive anatomic implant.

Indications

Best suited for patient with small breasts, that do not want autologous tissue reconstruction because of the scars left or because they prefer a simpler treatment with faster recovery.

Contraindications

Patients with very thin skin and maybe radiotherapy, because it increases the rate of complications, specially capsular contracture.

Advantages

The expanded skin has the same texture and color that the other breast and it is sensible. It needs a short surgical time and recovery is fast.

Disadvantages

The total time to finish the reconstruction is longer, it requires two operations and the result is not as natural as for autologous tissues, with lack of ptosis and a different aging that the contralateral side.

Complications

Acute complications are extrusion, infection, malposition and rupture. The account for 20% and after radiotherapy the rate can rise up to 60%. The main complication in the long run is capsular contracture (3% or more after radiotherapy)

3.2. Autologous tissue

3.2.1. Latissimus dorsi flap

It is a very useful flap because it is in vicinity to the area to be reconstructed. It is useful for partial reconstructions after tumorectomies or quadrantectomies or to cover an implant or expander in radical mastectomies.

Indications

As salvage for failed previous reconstructive attempts, in partial reconstructions, in obese or very thin patients where the DIEP flap is contraindicated. It is used to cover implants and expanders when the skin of the mastectomy is very thin.

Contraindications

Previous surgeries that could have injured the thoracodorsal vessels (toracotomies or axillary node dissection).

Advantages

It allows the reconstruction with an implant in one stage.

Disadvantages

It leaves a lengthy scar at the back.

Complications

As for implants and at the donor site we can have seromas, hematomas or conspicuous scars. There is a risk also for partial or total necrosis (loss) of the flap.

3.3. TRAM flap

3.3.1. Pedicled

Indications

Mastectomy defects requiring much tissue, in patients where the techniques have failed, patients treated with radiotherapy, patients with big, saggy contralateral breasts. The patient has to have enough tissue in the lower abdomen but with a BMI under 30.

Contraindications

Previous abdominal surgery such as cholecistectomy, coronary bypass if the vascular surgeon used the internal mammary artery for the reconstruction and former abdominoplasties. Obesity is a contraindication because there is a high risk for partial or total loss of the flap. Relative contraindications are smoking and diabetes.

Advantages

The final result is very similar to the contralateral breast and ages the same.

Disadvantages

Longer recovery, longer hospitalization stay. Normal activities are resumed 2-4 months after the treatment.

Complications

Infection (12%), seroma or hematoma (4%), partial necrosis (16%), total necrosis (1%). In the long run the main complication is abdominal weakness or even hernia (8%).

3.3.2. Free TRAM (microvascularized)

Indications/Contraindications

The same as pedicled TRAM, but the blood supply for this flap is more robust and reliable than the pedicled.

Advantages

Better blood supply and less risk for flap loss. Only a portion of the muscle is taken so there are fewer abdominal wall complications.

Disadvantages

Requiere entrenamiento microquirúrgico. Tiempo quirúrgico más largo. Requiere un control postoperatorio estricto para vigilar la viabilidad del colgajo.

Complicaciones

It requires microsurgical experience. The operating time is longer and it needs a strict postoperative surveillance

3.3.3. Perforator based flaps

3.3.3.a DIEP flap

DIEP flap is very similar to the free TRAM flap, but the blood supply is based only in 1-2 branches of the deep inferior epigastric artery. These arteries pierce the muscle (perforators). The branches are dissected down to their origin in the DIE artery so the muscle is not taken with the flap. This means that recovery of the abdomen is faster and there is no risk for hernia. It is very important to evaluate preoperatively which arteries supply the flap, to reduce operating time and ensure the survival of the flap. This is done with an angio TAC.

3.3.3.b Superior Gluteal Artery Perforator Flap

Indicated in patients without enough abdominal tissue and that do not want implants. The scar is left at the upper aspect of the buttock. The dissection is difficulty and it requires more expertise.

Breast reduction and tumorectomy

In patients with big breasts and isolated tumors we can adapt the pattern of breast reduction to treat tumors at any location in the breast. We can choose between different types of pedicles so the tumor is included in the area to be excised and the breast is rearranged as in any breast reduction to leave a normal, smaller breast. Indications are the same as for conservative surgery (tumors up to 4 cm) and always there is adjuvant radiotherapy. The reconstruction is immediate even preserving the nipple-areola complex. The contralateral breast is reduced as well to get symmetry. Recovery is as for any breast reduction, very quick. The main drawback is that there is higher risk for fat necrosis.

Fat grafting

Fat grafting is an useful technique for treatment of defects after conservative therapies and to improve the results achieved with the aforementioned procedures. It is a simple and safe procedure that we are performing very often to improve the cosmetic results in our patients. In some patients it is being used for total reconstructions, although in these cases we need several stages. The technique is based on the Coleman’s description, spinning the fat and injecting it with small syringes.

Contralateral breast

The contralateral breast has to be treated in most of the cases to get a good symmetry. We can use a wide array of techniques such as breast lift, breast augmentation or reduction. We usually do it in the first stage, when the breast is reconstructed.

Nipple-areola complex reconstruction

The final step is to reconstruct the areola and nipple. This is performed around 6-8 weeks after the reconstruction of the breast mound. We use local flaps for the nipple reconstruction and tattooing for the areola and giving the appropriate color to the nipple.

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1. 23 / Jul

   Antiaging Group BCN said…

   una explicación extensa sobre la cirugía oncoplástica de la mama http://cot.ag/c2vbMf Hay q dar la máxima información a la paciente ^EBe

   Reply

2. 12 / Nov

   Anna said…

   Me interesa esta operacíon. Yo tuve una mastectomia. Tengo 29 años. Cuanto tiempo llevara todo el proceso? Si me apunto, con que rapidez podriais empezar la operacíon y cuanto es su precio?

   Reply

   1. 14 / Nov

      AGB said…

      Hola Anna
      Hay que ver cual es la mejor opción. Dependiendo de la técnica puede demorarse más o menos. Lo ideal sería poder verla en la consulta para ver si es mejor una expansión o usar una reconstrucción con tejido autólogo. Intentamos resolverlo todo en una operación. Podemos financiarlo (hasta 5 años) y el coste está en función de la técnica. El proceso puede durar hasta un año, en función de la técnica (todo, incluido la reconstrucción de areola-pezón)
      Si vive lejos de Barcelona nos puede enviar unas fotos, en las que se vea abdomen y tórax. Si le interesa, puede ponerse en contacto con nosotros, rellenando este formulario de contacto, si lo prefiere puede hacer referencia a este comentario.
      Un cordial saludo,
      Dr. Benito.

      Reply