There are two types of breast reconstruction:
immediate and secondary.
Immediate reconstruction can be performed on highly localised forms of breast cancer where surgical intervention is the only option. In such cases the mastectomy and the reconstruction can be performed during the same procedure.
After the mastectomy, follow up treatment is usually required. This usually involves radiotherapy, which changes the property the quality of the skin. The surgeon assesses the condition of the skin six months to a year later and recommends the best course of secondary reconstruction. This is because the choice of secondary reconstruction is highly dependent on the condition of the skin of the patient, which cannot be properly assessed immediately.
In the intervening period patients can wear a removable external aid that provides an outwardly symmetrical appearance.
Several steps are required in reconstructive breast surgery. Firstly, the size and shape needs to be restored, always taking the utmost care to achieve symmetry between the breasts. Once this has been done the nipple and areola are then reconstructed.
Reconstruction using retropectoral prosthesis
This method involves placing the prosthesis underneath the pectoralis major muscle by tracing the scar from the mastectomy incision. This means the procedure produces no additional scarring, and no flap is required. This method is quick and the post-operative effects are minimal.
This method is reserved for women whose skin condition and scarring are in good condition and whose pectoralis major is normal and thick enough to completely cover the prosthesis. Apart from infection and hematoma, the main initial complication that can arise in breast reconstruction is that the skin starts to suffer due to an insufficient quality of the membrane. This skin suffering can lead to necrosis, leaving the prosthesis exposed. As this constitutes a failure of the procedure, it is of the utmost importance that the skin is in good condition before the procedure is attempted. Later complications include: the appearance of a periprosthetic tissue reaction, formation of a shell or thickening of the tissue (occurs in about 15-20% of cases) and deflation (shrinking) of the prosthesis due to contact with physiological saline. Although the shell may not be irritable and can be invisible to the naked eye, it may however, necessitate the removal of the prosthesis with a view to trying another reconstructive technique.
The lifespan of a breast prosthesis is highly unpredictable, as it is determined by a myriad of factors. Like any prosthesis (knee, hip) it will naturally degrade over time. In the case of a gel or fluid based prosthesis, a leak or failure will be noticeable due to the decrease in size of the breast. It should be noted that in such cases the leaked fluid is harmless. Silicone based prosthesis' may break and in cases where there is no associated trauma this can be difficult to detect as the silicone will remain in the prosthetic lodge. In both cases an intervention to replace the damaged prosthesis and check for the presence of a shell would be recommended.
Reconstruction by prosthesis after tissue expansion
Tissue expansion is a process that aims to stimulate tissue growth on the chest wall so as to more easily insert a breast prosthesis. This makes it much easier to create a final result that more accurately mirrors the natural shape of the breast. After inserting a tissue expander into the mastectomy scar, the tissue is then progressively expanded once a week by inflating it using a small valve. The amount of inflation performed will be relative to the desired final size. The duration of the expansion is usually 3 months.
The final prosthesis is then placed beneath the muscle. The advantages of this method are that it produces no additional scar and does not require a myocutaneous flap, which gives the appearance of a patch, and it produces the ideal prosthetic volume. It has the disadvantage that it requires additional surgery and weekly inflation. It is also difficult to perform on a patient whose tissue wall has been weakened due to radiotherapy, as this has the risk of the prosthesis becoming exposed. In some cases the large back muscle can be moved (with no additional scar) behind the skin in order to increase the body's tolerance to the expansion and improve the quality of the tissue wall.
Reconstruction using skin from the back and a prosthesis (myocutaneous flap using the latissimus dorsi)
The latissimus dorsi muscle has a reliable shaft (with a feeder artery and a drainage vein) that enables the creation of a myocutaneous flap (composed of skin and muscle with arteries and veins of this type). The procedure results in a dorsal scar. This technique causes few functional consequences.
It is possible to collect fat from a wide area of the dorsum in order to recreate the breast without using a prosthesis. This is known as an autologous. However in most cases an additional prosthesis needs to be added in order to achieve the desired shape and volume. In addition to the complications that arise from using the prosthesis, this procedure means that patients will be left with a dorsal scar, a noticeable different in skin colour and texture in the skin from the chest. Despite these limitations, the procedure can get excellent results in cases where the patient's tissue wall is too weak to support a full prosthesis (this usually occurs following radiotherapy).
Reconstruction using excess skin and fat from the abdomen (abdominal flap)
It is possible to perform breast reconstruction using the excess fat and skin removed from the abdominal region during a tummy tuck. The skin of the abdominal wall is provided with blood vessels by the periumbilical rectus that crosses through the large abdominal muscle. The large abdominal muscle serves as a vascular medium for the transfer of skin and abdominal fat to the chest. [Hartrampf, Bostwick] The TRAM (Transverse Rectus Abdominis Myocutaneous flap) technique can reconstruct the breast(s) with very favorable aesthetic results i.e. a natural immitation of size, shape, skin colour etc
