The physician will discuss with the patient what will occur during breast construction: during the mastectomy (immediate reconstruction) or subsequently (deferred reconstruction).
There are no absolute rules for determining the time to perform reconstruction. This varies from one patient to the other depending on several criteria, such as the effects of radiotherapy, spreading of the tumour and most of all, the desire of the patient herself to have this type of operation. Most patients wait approximately one year after an additional treatment of radiotherapy but some opt for immediate reconstruction.
The various types of breast reconstruction
Breast reconstruction can be performed using various surgical techniques:
- Reconstruction by prosthesis
- Reconstruction by a flap:
- Muscle and skin from the back
- Muscle and skin from the abdomen
- Cutaneous and fatty tissue from the abdomen
For each method, reconstruction of the areola and nipple is possible. The contralateral breast can be made symmetrical so that both breasts are very similar in shape and volume.
Reconstruction by prosthesis
This type of reconstruction may be considered if the skin and the large pectoral muscle are intact and substantial enough and if no radiotherapy has been administered. These tissues can in this case securely retain a prosthesis and give the breast a shapely contour.
The prosthesis will be placed behind the large pectoral muscle, taking up a portion of the mastectomy scar tissue. The prosthesis is an anatomical type of prosthesis (in the shape of a drop) made of silicone gel.
In some cases, the prosthesis is attached to a small valve placed under the skin of the chest. The concept of this type of reconstruction is based on the principle of tissue expansion, meaning the ability of skin and muscle to gradually expand. When the prosthesis is put in place, the portion in saline solution is empty. It will be gradually filled by weekly injections into the valve through the skin, under local anaesthesia. The injection is painless; the increase in volume will simply produce a sensation of tension for 24 hours after the injection.
The advantage: there are no additional incisions and duration of the operation and the hospital stay is shorter.
The disadvantage: the prosthesis does not change over time as the other breast does; its shape is set.
Reconstruction by a flap from the back
A flap containing the large dorsal muscle, and the skin and fat covering it, is ideal for reconstruction.
The skin taken up is in the shape of a spindle and will be used to reconstruct the underside of the breast. Volume will be obtained by muscle and fat. Sometimes it is necessary to put a prosthesis under the muscle to achieve the proper volume. On the back, the residual scar will usually be horizontally shaped, and hidden under the brassiere band.
Hospitalisation usually lasts a week. After the operation, the drains are left in place for several days. There is no cause for fear of disability in the use of the arm.
The disadvantages: the necessity of creating an additional scar on the back. A pouch of lymph fluid may also appear on the back. This pouch will be emptied by a simple puncture. One contraindication for this operation is periarthritis.
Reconstruction by TRAM (Transverse Rectus Abdominis Muscle flap)
Vascularisation via the transverse rectus abdominis muscle (TRAM) flap is a means of removing excess skin and fat from the abdomen for breast reconstruction.
The transverse rectus abdominis muscle extends from the chest to the pubis and plays a part in the functioning of the abdominal girdle. All of the tissue is tucked under the skin of the abdomen, which must be completely detached, and it is relocated to the breast under construction. In order to repair the defect in the abdominal wall, it is often necessary to use a synthetic plate (this is actually a solid but flexible net).
The suture made in the abdomen will leave a long horizontal scar extending from one hip to the other.
The skin and fat making up the breast are remodelled to recreate the volume and shape of a natural-looking breast. This operation takes a long time to perform. The hospitalisation period is 8 days. Scar-healing does not always occur rapidly.
The advantages: very natural results in the reconstructed breast and an improved abdominal silhouette.
The disadvantages: minor problems, due to poor vascularisation of the flap, can occur periodically. Some parts of the flap may not survive and healing will be achieved by local treatment. There may be significant abdominal discomfort in the first instance, forcing the patient to retain a slightly bent-over posture. There will be persistent abdominal weakness, which could be bothersome for sportswomen.
This operation is an option only if the woman has an excess of skin and fat around the abdomen and if she has not previously had abdominal or gynaecological surgery. Cessation of tobacco use at least two months prior to the operation is mandatory.
Reconstruction by a flap of skin and fat from the abdomen or DIEP-flap (Deep Inferior Epigastric Perforator flap)
Thanks to the development of microsurgery, it is now possible to transplant quantities of skin and fat from the abdomen to the breast to be constructed, without sacrificing the transverse rectus abdominis muscle as a result. The wall of the abdomen consequently repairs itself very easily and requires no reinforcement.
The scar on the abdomen is horizontal, extending from one hip to the other. The skin and fat making up the breast are sculpted to recreate a harmonious shape and volume.
This surgery is long, with a hospitalisation period of at least one week. Post-surgical discomfort is usually well tolerated and patients resume physical and sports activities after six weeks.
The advantages: very natural results in the reconstructed breast and an improved abdominal silhouette while retaining abdominal wall strength.
The disadvantages : microsurgical ones, meaning that the graft may fail and it may be necessary to remove the reconstructed breast.
Cessation of tobacco use at least two months prior to the operation is mandatory.
Reconstruction of the nipple
Reconstruction of the areola and nipple is possible. Generally, it is necessary to wait several months until the new breast has assumed a somewhat definitive shape. The areola and the nipple are reconstructed either with a local flap, or by a graft from, for example, the nipple and areola of the contralateral breast, or even using a graft from the skin of the groin. Oftentimes, the various methods will be combined. The areola and nipple can also be applied as a tattoo.
Symmetrisation compared to the contralateral breast
In practical terms, it is sometimes difficult to reconstruct one breast identical to the other one. The contralateral breast can be made symmetrical in order to obtain more aesthetically pleasing results. Irrespective of the type of reconstruction chosen, subsequent oncological monitoring can be applied as safely as prior to reconstruction. These various techniques are also used for breast reconstruction during a mastectomy.
Health insurance funds and insurance companies reimburse a large portion of the costs of reconstruction of the operated breast and surgery on the other breast.