Breast reconstruction

In general, all mastectomized women can undergo reconstruction surgery.

In some cases, if the patient wishes, the reconstruction can be carried out at the same time as the mastectomy – that is to say, during the same surgical procedure. This is known as immediate reconstruction. The procedure requires close collaboration between the surgeon who removes the breast and the plastic surgeon, since both must be present. This means that immediate reconstruction is not possible in hospitals without plastic surgeons (for example, in regional hospitals). Nowadays, immediate reconstruction is the norm: its advantages are that it usually obtains better aesthetic results, entails less psychological strain, and reduces the costs associated with multiple reoperations. However, it can only be performed in patients with early stages of the disease (Stage 1 and 2).

As soon as a woman is diagnosed with breast cancer, she should be informed about the possibilities of reconstruction. The surgeon who performs the mastectomy, the oncologist, and the plastic surgeon must work together to develop a strategy that can achieve the best possible outcome.
The plastic surgeon is a specialist who has the technical skills required to reconstruct a natural-looking breast. After assessing the patient’s general condition, the surgeon will inform her of the available options, taking into consideration her age, general health status, physical and anatomical characteristics, and future expectations.
Breast reconstruction in Maresme is covered by Social Security, provided that the hospital has a plastic surgery team. Most private insurance policies also cover this procedure.

Reconstruction can be performed with silicone implants or with the patient’s own tissue in the form of flaps created using microsurgery techniques.

In immediate reconstruction, in some instances the implant can be inserted directly. In the case of delayed reconstruction, a tissue expander must be placed prior to the definitive implant. Delayed reconstruction is usually indicated in thin patients with small, non-sagging breasts. The technique involves at least two interventions: during the initial surgery, a tissue expander is inserted, either immediately after the mastectomy or later. Once the wounds have healed the expander is filled gradually every 1 or 2 weeks. In a second intervention, between 3 and 6 months after the placement of the expander, the second stage of the surgery is performed, in which the expander is replaced by a silicone gel prosthesis. Smoking and prior or associated radiotherapy may be contraindicated in this type of reconstruction as they increase the incidence of complications. In this reintervention, the expanded or preserved skin is sensitive and has the same characteristics as the adjacent skin in terms of colour and texture. Surgical and post-operative recovery times are shorter than in breast reconstructions with autologous tissues, and, from the technical point of view, the intervention is easier to perform. Conversely, the total reconstruction time is longer in case of a delayed reconstruction since the procedure involves the placement of the expander, the expansion process, and the replacement with the definitive prosthesis. As regards the long-term results, the breast’s appearance tends to be less natural and the contralateral breast ages at a different pace; this means that some retouching is often required.

Another option is reconstruction using the patient’s own tissue, obtained in the form of flaps from parts of the body other than the breast. There are many types of flaps of diverse origins, but breast reconstruction is mainly performed with tissue from the back and the belly. Breast reconstruction with a wide dorsal muscle flap is indicated in:

• Previous failure of reconstruction with implants or any other flaps.
• Partial reconstruction of a mastectomy or nodulectomy defect, quadrantectomy or lumpectomy.
• Obese patients.
• Extremely thin patients.
• Patients with contraindications for microsurgical flap.
• In reconstruction with breast implants, mastectomized patients whose skin flaps are too thin to cover an implant.

However, this procedure cannot be performed when the thoracodorsal vascular pedicle may have been injured – for example, in case of thoracotomies or major associated pathologies.

Finally, there are two other types of flaps that come from the belly and are created using microsurgery techniques: muscle flaps (TRAM) and perforator flaps (DIEP). In the DIEP flap, the skin of the belly is used but the anterior rectus muscle is preserved; the scar is similar to the one that appears after a tummy tuck. This procedure maintains the abdominal muscles intact and avoids the complications that emerge due to muscle weakness when the anterior rectus muscle is used. What’s more, the immediate result is aesthetically pleasing, and over time the aging of the tissue will be symmetrical and the natural fall of the breast is preserved. Psychologically, the patient’s self-image is enhanced by the breast reconstruction and the improved abdominal contour. The main limitation for this type of microsurgical techniques is that it must be performed by a microsurgical medical team who have received specialist training in this approach.

The result obtained after a breast reconstruction is definitive and enables the patient to lead a normal life. In some cases, the reconstructed breast may have a firmer appearance and seem rounder than the other breast. The contour may not be exactly the same as before the mastectomy, and there may be some differences in symmetry with respect to the non-intervened breast. However, these differences are usually only apparent to the patient herself.
For the vast majority of mastectomized patients, the reconstruction of the breast substantially improves the patient’s body image and restores her psychological balance which may well have been affected by the disease. The patient is soon able to enjoy a full social and sexual life and forgets all about the disease that made the reconstruction necessary.

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