Breast reconstruction
One woman in nine experiences breast cancer over her lifetime. The number of survivors is expected to rise in the next decade. Although breast conserving surgery and radiotherapy are one of the mainstay of treatment, total mastectomy still is a frequently offered solution in a therapeutic and prophylactic manner.
The mastectomy defect can be devastating both psychologically and physically on many women. Extensive literature clearly supports the oncologic safety and advantages (improvement in body image, quality of life and mental health) of breast reconstruction.
Breast reconstruction aims to restore the shape and volume of the breast after mastectomy or, in selected cases, after breast-conserving surgery.
Reconstruction may be performed using a breast implant, the patient’s own tissue, or a combination of both. It can be performed at the same time as the mastectomy or at a later stage.
There is no single technique that is best for every patient. The appropriate reconstruction depends on the type of cancer surgery, the need for radiotherapy, the quality of the remaining breast skin, the available donor tissue, previous surgery and the patient’s own priorities.
Breast reconstruction is also a choice. Some women prefer not to reconstruct the breast after mastectomy, and this should be discussed with the same consideration as the reconstructive options.
Implant-based or autologous reconstruction?
-
Single-stage breast implant under the pectoralis major muscle at the time of the mastectomy
Breast tissue expander at the time of the mastectomy then delayed implant
It has a shorter initial operation and avoids a separate donor site. Capsular contracture, implant exposure, infection and the effects of radiotherapy are important considerations.
A Breast tissue expander can also be combined with an autologous flap.
-
Uses the patient's own tissue to reconstruct the breast.
The tissue can be transferred from the abdomen ot back depending on the patient's anatomy and previous operations.
Options include:
DIEP flap reconstruction using skin and fat from the lower abdomen
Latissimus dorsi flap reconstruction using tissue from the back, sometimes combined with an implant or fat grafting
Autologous reconstruction involves a longer and more complex operation and creates a scar at the donor site. Its main advantage is that the reconstructed breast consists largely or entirely of the patient's own living tissue.
What does radiotherapy change?
Radiotherapy is an essential part of breast cancer treatment for many patients, but it also affects the tissues used for reconstruction.
Radiation can cause progressive fibrosis, reduced tissue elasticity and changes in the skin and underlying soft tissues. In implant-based reconstruction, this is associated with a higher risk of capsular contracture and reconstructive complications.
Autologous tissue generally tolerates the long-term effects of radiotherapy better than an implant reconstruction, particularly when reconstruction is performed after radiation. However, radiotherapy can also affect a flap, and the timing of reconstruction therefore needs to be considered individually.
The need for radiotherapy does not automatically determine one reconstructive pathway. The oncologic treatment plan always comes first, and the reconstruction is designed around it.
When can breast reconstruction be performed?
-
Immediate reconstruction is performed during the same operation as the mastectomy.
Preserves much of the native breast skin and, when oncologically appropriate, sometimes the nipple and areola.
Maintains the breast envelope before significant scarring occurs.
Can be performed using an implant, tissue expander or autologous flap.
Avoids a period without a reconstructed breast, although further procedures may still be required.
-
Reconstruction is performed after the mastectomy, sometimes months or years later.
May be chosen when reconstruction was not desired or appropriate at the time of mastectomy.
Allows cancer treatment to take priority when necessary.
Remains possible even many years after mastectomy.
After radiotherapy, autologous tissue can be particularly useful to replace or supplement irradiated skin and soft tissue.
-
Some reconstructions are deliberately performed in several stages, called delayed immediate reconstruction.
A temporary tissue expander may be used to preserve or progressively recreate the breast envelope.
It can later be exchanged for a permanent implant or replaced by autologous tissue.
Secondary procedures such as fat grafting or surgery to improve symmetry may form part of the reconstructive plan.
Reconstruction is a process
Breast reconstruction should not necessarily be viewed as a single operation.
Even when the breast mound is reconstructed during the mastectomy, secondary procedures may be useful to refine its shape or symmetry. These can include fat grafting, scar revision, surgery to the opposite breast and, when desired, nipple–areola reconstruction.
The objective is not simply to replace the volume removed during mastectomy. Reconstruction involves recreating a breast shape while working within the limitations imposed by the cancer operation, the remaining tissues and any additional treatment.