Reconstructive breast surgery
Reconstruction after breast cancer
In France, breast cancer is the most common cancer in women, affecting approximately 1 in 10 women
The managementof breast cancer is multidisciplinary, involving surgeons (gynecologists, plastic surgeons), oncologists and radiologists.
Treatment usually combines surgery to remove the tumor and medical treatment (chemotherapy, hormone therapy) and / or radiotherapy.
Depending on the type of cancer and its evolution, the surgical treatment can be :
- either a conservative treatment (lumpectomy or zonectomy) which consists of removing the tumor and some surrounding healthy tissue ;
- or the complete removal of the breast (mastectomy), which involves removing the entire mammary gland and more or less of the skin covering it.
This breast ‘disfigurement’almost always justifies the use of breast reconstruction. The reconstruction is an integral part of the management of breast cancer.
When is the right time to benefit from breast reconstruction ?
Breast reconstruction can be immediate or deferred :
- Immediate breast reconstruction is done after the mastectomy during the same procedure. For a better cosmetic result and to avoid a number of complications, immediate reconstruction is preferred for cases where no additional radiation therapy is indicated (in situ cancers) ;
- The deferred reconstruction is scheduled for at least one year after the end of radiotherapy (for better healing) and at least 6 months after the end of chemotherapy (to be in good condition). The time interval between the breast removal and reconstruction should allow the patient to mourn the loss of the breast.
Techniques for breast reconstruction
Whenever possible, Dr. Laveaux prefers autologous reconstruction, using the skin and fatty tissue from the patient. Then, the result is natural and long-lasting
It is necessary to differentiate the total breast reconstruction after the mastectomy from the reconstructive surgery following a conservative treatment.
Breast reconstruction after mastectomy
The plastic surgeon has several objectives :
- replace skin removed during the mastectomy ;
- recreate the volume ;
- recreate the sub mammary fold ;
- reconstruct a nipple-areola complex.
The latissimus dorsi flap :
The latissimus dorsi is a large and flat back muscle whose function is non-essential. Functional consequences due to the removal of this muscle are negligible. It can be peeled back and survive due to a small vascular pedicle located in the armpit, and be transferred to the breast to be reconstructed in the mastectomy scar. It helps restore volume and serves as a medium in which fat is injected to increase the volume of the reconstructed breast.
It may be used alone (purely as a muscle flap) or used with a skin paddle (myocutaneous flap), to cover the missing skin on the breast, but it causes an unsightly "patch".
The scar caused by the removal of the latissimus dorsi muscle is concealed when wearing a bra. It is thin as the closing is done without tension.
The abdominal advancement flap :
The abdominal advancement flap allows the transfer of skin by stretching up a part of the excess abdominal skin. In this case, there is no "patch" effect like with the latissimus dorsi flap.
The abdominal flap advancement also can recreate an inframammary fold. Incidentally, it slightly increases the volume and projection of the reconstructed breast.
The lipofilling :
The lipofilling (fat injections) increases the volume of the reconstructed breast, or even both of the breasts. This is an aesthetic improvement to areas that have been liposuctioned.
The French Society of Plastic, Reconstructive and Aesthetic Surgery (SOFCPRE) issued recommendations for fat injections to the breast : read (in French).
Breast implants :
Implanting breast prosthesis can restore volume. This method is indicated when an implanted is required for two breasts or where fat reserves are insufficient to perform lipomodelage.
In breast reconstruction, polyurethane implants are strongly recommended for a more natural and long-lasting result.
Reconstruction of the nipple-areola complex :
The areola is reconstructed by a tattoo, by skin graft or simply by using adhesive silicone prosthesis.
The nipple is reconstructed using a small local flap or by grafting half the nipple removed from the other breast.
The reconstruction of the nipple-areola complex is the last step of breast reconstruction because the shape of the reconstructed breast must be stabilized.
Other techniques :
Other breast reconstruction techniques are much more complex and can cause a higher risk of complications. This is the case of the rectus abdominis flap (TRAM) or free flap (DIEP) or other free flaps (buttock, gracilis) These techniques are preferred for rare and special cases.
The surgeon has several methods that are associated together to establish a reconstruction program that suits every patient. This program is established taking into account the wishes of the patient but also the technical possibilities related to the morphology of the patient (shape and volume of "normal" breast, fat reserves related to the whole body).
For a good quality breast reconstruction, 2-3 operations are usually needed. The time interval between the two operations varies between 3 to 6 months.
Broadly speaking, the first operation under general anesthesia is the most complex (2-3 hours) and allows for a latissimus dorsi flap and / or abdominal advancement flap to be used. The hospital stay is 3 to 5 days. The following procedures include injecting of fat, harmonising the other breast and reconstructing the nipple-areola complex. They take place under general anesthesia with the duration varying from 1 to 2 hours. The hospital stay is 24 hours. Only isolated reconstruction of the nipple-areola complex can be performed under local anesthesia on an outpatient basis.
Correction of the side-effects of conservative treatment
A Lumpectomy decreases the volume of the breast. Radiation causes skin retraction. Breasts that received conservative treatment may therefore have some unpleasant side-effects of depression, intussusception, higher volume loss in one breast compared to the opposite one, ...
In almost all cases, the lipofilling (fat injections) will, in one or more sessions, significantly improve the aesthetic result.
In certain rare and more complex cases with significant volume loss and tightening of the skin, the latissimus dorsi flap can be proposed with or without additional fat injections.
Whatever the type of reconstruction, it is quite common for the non-reconstructed breast to need a surgical procedure in order to achieve good chest symmetry. This procedure could be a change in breast volume (reduction or augmentation) and / or a change in shape (treatment of ptosis).
Cosmetic breast surgery and cancer
Cosmetic breast surgery (reduction or increase in volume, improvement of the shape) does not encourage the occurrence of breast cancer or any other cancer.
However, the radiological assessment performed before the procedure or analysis of removed breast tissue can sometimes help identify an undetected breast lesion.
Finally,after a breast operation, clinical and radiological monitoring can be made more difficult. This is why a radiological examination is often required after surgery to serve as a reference to the radiologist who can compare this review to future examinations conducted during the life of the patient
Breast reconstruction and risk of cancer recurrence
Breast reconstruction has no influence on the risk of recurrence of breast cancer. Reconstruction does not increase the risk, it does not diminish it either. Any additional treatments (chemotherapy, radiotherapy, hormone therapy) are possible, as well as post-treatment monitoring. Exceptionally, the reconstruction allows diagnosis of any recurrence or of early breast cancer in the contralateral breast (in a breast reduction resulting from breast symmetrisation due to the systematic analysis of the removed gland.
Author: Dr. Christophe Laveaux
Specialist in aesthetic surgery - Antibes
Reproductions, even partial, of the texts are allowed on the express condition cite the author (Dr. Christophe Laveaux) with a direct link to the article mentioned.