Breast reconstruction surgery after cancer disease

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Breast reconstruction surgery after cancer disease

Breast tumours are one of the most frequent cancers in women. Immediately the word malignant evokes anxiety stemming from the unpleasant prognosis, fear and damage to the body by the surgery. The last factor is significant especially in younger women, where we come across the phenomenon called dysmorphobia, i.e., fear of a distorted body image.

It is a natural consequence of the cultural perception of women that breasts are considered to be a symbol of womanhood. It is demonstrated by findings of ancient and medieval artifacts plus today's view on this functionally and aesthetically important organ. It is abundantly clear how hard it is for a woman to have a breast removed due to cancer (amputation, breast ablation or mastectomy). Therefore any return of lost confidence in a woman's private and social life by reconstruction surgery is often of the same importance as the surgical removal of the breast tumor. As with other oncological diseases, even the complex care in women with significant breast disease is a team treatment.

Breast reconstruction after mastectomy has developed greatly in the last decades. There is perhaps no other cancer that has seen so many revolutionary changes in surgical treatment. It concerns not only the change from overly radical methods of primary surgery to more conservative procedures, but also the timing of breast reconstruction surgery after mastectomy. There are many statistical data, not only from the United States, about increasing the number of so-called immediate reconstructions, when the breast shape and size is reconstructed at the same time as the removal of the tumour.

Historical sources on breast cancer and its surgical treatment lead far back to ancient times; however, this can't be said for breast reconstruction surgery after the removal of malignant tumours. A key moment for breast reconstruction surgery has to be the discovery of silicone implants by Cronin and their usage in aesthetic surgery in 1963. 14 years later in 1977, the implant was for the first time used for breast reconstruction after cancer. Since then there are other surgical procedures using not only synthetic materials, but also the patient’s own tissue or a combination of both. Due to the increase of qualified microsurgeons specialised in aesthetic breast surgery, the development of microsurgical approaches after breast reconstruction represents a further important step. With the aid of the free transfer of tissue complexes, it is possible to get a large amount of the patient’s own tissue suitable for breast reconstruction.

The timing of the reconstruction can be immediate or delayed. An immediate reconstruction is performed concurrently, so there should be cooperation between the general surgeon and the plastic surgeon. The great advantage of this method of reconstruction is the fact that there is no psychological impact on the woman as a result of the loss of the breast. An immediate reconstruction nowadays is mostly used during preventive removal of a risky mammary gland. If the immediate reconstruction is not possible, a delayed reconstruction can be considered in 12 to 24 months or more.

Breast reconstruction surgery after cancer disease

Reconstruction of the entire breast:

For reconstruction of the entire breast after radical mastectomy we can use synthetic materials (implants), autologous tissue (body’s own) in combination with synthetic material or just the autologous tissue.

Reconstruction using synthetic material:

Nowadays silicone implants are mainly used, comprised of synthetic material filled with gel or saline. Although silicone implants were used immediately after their invention by Cronin for breast augmentation in aesthetic surgery, the first signs of their use for breast reconstructions after mastectomies can be found in 1977. Since then their number has increased greatly. They are used either as a simple implant insertion into a remaining skin flap or in a combination of so-called tissue expansion of insufficient fold (gradual expansion and enlargement of the skin fold with the help of an expander). In other words, silicone bags inserted under the skin are filled with saline solution at certain periods of time until they result in the desired expanded skin fold.

Breast reconstruction with the use of autologous tissue and synthetic material:

The combination of the patient’s own tissue with a silicone implant represents one of the basic methods of breast reconstruction surgery at some clinics. It is used when there is a lack of skin and its quality does not enable simple implant insertion, or in cases where the breast on the undamaged side is heavier and appears to sag.

Autologous tissue from the side of the chest is often used to add to and increase an insufficient skin flap on the front of the chest. This way we get space for the implant, which we insert under the big breast muscle. After a period of 3 months, we reconstruct the areola and the nipple.

Another option for this reconstruction method is the so-called free abdominal flap, which ensures a sufficient skin fold to cover the implant by pulling the abdominal wall upwards.

Another way to use the autologous tissue in combination with the implant is to rotate the big dorsal muscle with the skin fold to the front of the chest. The procedure is more time-consuming, but nevertheless preferred at some clinics - mainly abroad. Even here it is only possible to reconstruct the areola and the nipple after 3 months.

Breast reconstruction with autologous tissue:

Breast reconstruction with the use of only autologous tissue represents another important change in this area. The big advantage is that it doesn't have to be combined with an implant to enlarge the volume. The disadvantage is the difficulty and duration of the surgery. The frontal abdominal wall serves as donor tissue. Many clinics prefer this reconstruction method because it offers skin and fat in sufficient amounts, even for the reconstruction of a large breast.

The abdominal flap used for breast reconstruction can be of two types. A pedicle flap is the oldest method of breast reconstruction with vital tissue and is still used at clinics that do not have microsurgical techniques. The surgery consists of the separation of the large abdominal flap and its rotation on a pedicle formed by the muscle and vessels to the desired place on the front of the chest.

The second type of abdominal flap is a so-called free abdominal flap. It is formed by the free transfer of tissue from the abdomen to the chest and its reconnection to the blood vessels under microscope, which brings back blood circulation into the flap. The advantage of this free flap is a better blood supply than in the pedicle flap and also the smaller impact on the muscles of the abdominal wall. A highly trained microsurgical team is necessary for this type of procedure.

Reconstruction of part of the breast:

During the last few years, conservative approaches to surgical treatment of breast tumours have become more common than in the past. These mainly include breast-sparing procedures, where the tumour is removed but the majority of the breast remains undamaged. The breast changes to various extents, although these surgeries respect the shape and also the volume of the original breast. It also depends on the size of the tumour and its position.

Breast reconstructions after these so-called partial procedures are very diverse and they depend on the size of the defect after the removal of the tumour and the place where the tumor was located. For example, there is breast modification, where we perform an immediate reconstruction after the removal of a small tumour. It is the same method used to correct sagging breasts. Usually it is also necessary to modify the other side. Another reconstruction technique after a partial procedure is local flap cosmetic surgery in combination with synthetic material. Another type is the direct implantation of prosthesis to enlarge a defective breast. Overall there are many methods, too many even to mention in this article.

Areola and nipple reconstruction:

Reconstruction of areola and nipple represent the final phase of breast reconstruction after mastectomy. For most women it is a symbol of complete breast reconstruction with the possibility of a return to a full personal and social life. Formed areola and nipple complex gives the reconstructed breast a natural look, brings symmetry and therefore supports a woman's body perception as an undamaged unit. Reconstruction of the areola-nipple complex is divided into two units – the areola and the nipple.

There are three basic surgical techniques for areola reconstruction:

Transfer of part of areola from the other breast

Skin graft from places with more intense pigmentation (e.g., from upper inner thigh)

Using artificial tattoos

Nipple reconstruction offers a large number of surgical approaches; they can be again divided into three basic groups:

Transfer of part of the nipple from the second breast

Nipple reconstruction by local flaps

Using artificial tattoos

Complications:

Complications associated with breast reconstructions after mastectomies can be caused by the wrong choice of reconstruction method, imperfect surgical technique, local tissue insufficiency (irradiation, scars, etc.) and state of health (obesity, immune defects, diabetes, endocrinological diseases, cardiovascular diseases, smoking, age). With reconstructions using implants, complications are usually a hardening around the implant. With reconstructions with local flaps in combination with implants, the edge of the flap might sometimes separate and leave the implant uncovered. It is very rare, but if this happens the implant must usually be removed and a gradual expansion performed followed by new implantation of the prosthesis after several months. An abdominal flap can also be used.

Other potential complications include infection in the wound, hardening scars after surgery and swelling caused by the accumulation of spinal fluid. With abdominal flaps, there can be damage caused by inadequate blood flow to part or, exceptionally, even the entire flap. In the case of too large a loss of flap, it is necessary to choose another reconstruction method. In general, the aforementioned complications occur in no more than 15% of performed reconstructions.

breast reconstruction, cancer disease