Delayed breast reconstruction after mastectomy surgery
The total removal of the breast (also known as mastectomy surgery) constitutes a real mutilation affecting the symbol of feminity, which may cause major psychosocial impact.
It can be immediate (at the same time as mastectomy surgery) if no additional radiotherapy is considered, or delayed (6 months to 1 year after the end of medical treatments).
Delayed breast reconstruction surgery is a long procedure taking place on several steps over a period of 6 to 12 months.
Breast reconstruction objectives and techniques
It includes three main objectives:
- To reconstruct the breast shape and volume.
- To symmetrize the remaining breast to the reconstructed breast to obtain a harmonious outcome (via classical techniques: breast reduction, breast lift surgery or breast enlargement surgery depending on the case).
- To reconstruct the nipple and the areola.
The reconstruction of the breast shape and volume can be achieved by:
- An implant.
- A flap (tissues taken from the back or abdomen areas).
- Fat injections (breast lipofilling).
- A heterogeneous technique (flap + lipofilling, flap + implant, lipofilling + implant).
- Dr. Petit will begin with questioning your medical and surgical history as well as your family and personal history of breast cancer, and your tobacco consumption.
- He will listen to you in order to understand your wishes and your expectations relating to the breast reconstruction.
- He will suggest the most appropriate surgical strategy corresponding to your anatomy and your request.
- He will carry out a detailed clinical examination in order to assess: the quality (thickness and suppleness) and the quantity of thoracic skin within the mastectomy area, the shape and the volume of your controlateral breast, the donor areas of flap (back, abdomen), fat reserves.
- Dr. Petit will provide information on the scar positioning, treatment process and procedure limits, post-operative recoveries as well as main risks, so as to make an informed decision.
Breast reconstruction using an implant only:
It refers to the simplest breast reconstruction method, enabling to reconstruct the breast shape and volume when there is a high-quality thoracic skin. A one-stage reconstruction is possible when the quantity of thoracic skin is sufficient.
If this one is not sufficient, two surgical stages are necessary:
- The first surgical stage, known as tissue expansion, consists in inserting a deflated tissue expander connected to a subcutaneous valve underneath the thoracic skin and the pectoralis major muscle. Weekly inflating of the tissue expander with physiological saline solution is initiated once the healing is achieved, in order to distend the thoracic skin gradually.
- The second surgical stage replaces this temporary tissue expander with a definitive breast implant pre-filled with silicone gel.
The quality of implant-based reconstruction will depend on:
- The thickness and the suppleness of the thoracic skin.
- The suppleness of the capsule (physiological membrane) being formed around the implant.
- Simple et fast technique.
- Good aesthetic results if local conditions are favourable.
- No « patch » effect due to a flap (different coloration between the flap skin and the breast skin).
- No additional scar on the body.
- Inappropriate technique in case of previous radiotherapy.
- Greater risks of infection, of a scarring disunity and implant exposition, of a shell (stiffness of the capsule around the implant).
- Prothetic aspect of the reconstructed breast (more frozen) et ne
- vieillissant pas de in the same way as que le sein controlatéral.
- Need to change the implant in case of implant wear.
Breast reconstruction with latissimus dorsi musculocutaneous flap:
It refers to a very common breast reconstruction method when the quality of the thoracic skin is poor, especially after radiotherapy. It consists in taking tissue from the back area (range of skin + fat + latissimus dorsi muscle) and in shaping them in the thorax area to reconstruct the breast shape. Generally, the volume of the reconstructed breast is not sufficient with the latissimus dorsi musculocutaneous flap. Hence, it is necessary to increase the volume of the breast:
- Either to add an implant beneath the flap in one single operation.
- or to perform fat injections into the flap in a second stage. Several lipofilling sessions can be necessary to reach the requested volume.
This flap cannot be taken in patients who use crutches or practice climbing (because the back muscle enables to perform pull-ups with arms).
- Appropriate technique if you have a history of radiotherapy.
- Good aesthetic results even if the local conditions are unfavourable.
- Reliable flap (rare necrosis).
- No functional sequelae (no restriction on the arm movements).
- Possibility to increase the volume of the reconstruction with implant or lipofilling.
- « Patch » effect of the flap.
- Additional scar in the back area.
- Persistent discomfort in the back area is possible in some patients.
- The reconstructed breast is sometimes slightly mobile during some movements.
Breast reconstruction with latissimus dorsi muscle flap only as well as implant:
This reconstruction technique was developed by Pr. Maurice Mimoun.
It is aimed at patients with:
- a poor quality thoracic skin after radiotherapy, excluding the placement of an implant immediately.
- A thin silhouette without fat reserve.
- The back or the abdomen areas which do not constitute a satisfactory donor area for a flap.
Breast reconstruction with latissimus dorsi muscle flap only as well as implant implies three stages during the operation:
- The first stage consists in taking the latissimus dorsi muscle from the back area, and in transferring it beneath the thoracic skin in order to increase its thickness. The taking is performed from the extension of the mastectomy scar located under the armpit. Thus, there is no scar in the back area.
- The second stage (achieved six months later) consists in placing a tissue expander beneath the thoracic skin and the underlying muscles (pectoralis major muscle and latissimus dorsi muscle). The principle is to distend the thoracic skin gradually (refer to the section relating to breast reconstruction using an implant only).
- The third stage replaces this temporary tissue expander with a definitive breast implant.
- Identical to the latissimus dorsi musculocutaneous flap.
- No « patch » effect of the muscle flap (hidden beneath the thoracic skin).
- No scar in the back area.
- Longer and more difficult reconstruction technique.
- Persistent discomfort in the back area is possible in some patients.
Breast reconstruction with fat transfer (breast lipofilling)
This technique uses the fat reserves of the patient to reconstruct the shape and the volume of the breast.
The fat is taken from the hips, the abdomen, the thighs and the inner side of the knees. The fat is passed to the centrifuge in order to obtain fat without impurities before being reinjected at the level of the mastectomy area.
The breast reconstruction implies several sessions of lipofilling to achieve the requested volume. The number of de sessions is variable depending on the patient.
The main factor limiting the fat taking is a history of radiotherapy. This is the reason why, it is possible to combine with the BRAVA system in this case.
This process enables to unstick and soften the thoracic tissue thanks to a « cover » or « external suction cup », put on the mastectomy area ten hours a day (in the night generally), three weeks before and two weeks after each session of lipofilling.
- Very good aesthetic results enabling to achieve a breast with natural and stable as well as long-lasting aspects.
- No « patch » effect of a flap.
- No additional scar (except micro-incisions relating to the liposuction).
- Refinement of the silhouette.
- An often high number of necessary sessions (especially in case of radiotherapy).
- The limitation of the BRAVA system.
- The risk of failure of lipofilling surgery in some patients.
Breast reconstruction with the abdomen flap (DIEP):
This reconstruction technique uses the cutaneous and fat excess of the subumbilical abdomen in some women.
It implies microsurgery techniques and close surveillance after the operation. Dr. Petit cannot perform this procedure at the clinic, but he will suggest you to turn towards a hospital staff.
Nipple areolar reconstruction
The reconstruction of the nipple areolar plaque is the last stage finalizing the breast reconstruction.
The nipple can be reconstructed in two ways:
- With a composite graft taken from the controlateral breast (when it is a high volume breast).
- With a local cutaneous flap (known as flap of Little).
Two techniques are possible concerning the areolar reconstruction:
- A total skin graft taken from the genitocrural furrow area.
- A tattoo.