Mastectomy (breast removal) with breast reconstruction

Time of reconstruction

A breast reconstruction can be performed immediately, at various times:

• immediately: i.e. at the time of the mastectomy = primary breast reconstruction
• at a later stage: in this case, a wait-and-see attitude is adopted for about six months to a year (at least six months after the end of radiotherapy) = late or secondary breast reconstruction.

Benefits of immediate breast reconstruction

It is clear that this procedure is less psychologically stressful for the woman. It is only one operation and one anaesthetic. So, only one risk of complications and only one rehabilitation is necessary.

Type of breast reconstruction

We can divide breast reconstruction into two major groups, namely prosthetic reconstruction and autologous reconstruction.

1. Prosthetic reconstructions
   A silicone prosthesis is inserted under the large pectoral muscle. This is a silicone rubber shell filled with either silicone gel or saline solution. The prosthesis has a rough outer layer, as this reduces the risk of capsular contracture around the prosthesis. Such reconstructed breasts often feel less natural. In addition, radiotherapy after prosthetic reconstruction is virtually impossible.
2. Autologous or own tissue reconstruction
   This newer method involves transferring a large piece of skin and fatty tissue to the breast area in order to shape a new breast. With this type of breast reconstruction, a subcutaneous prosthesis is no longer needed, which also makes the new breast feel more natural. In addition, such a reconstruction is permanent, in contrast to a prosthetic one. Various types of flaps can be used for this procedure.

Tissue from the abdominal wall: The free 'DIEP' flap (deep inferior epigastric perforator flap)

The fatty tissue of the abdominal wall between the navel and the pubic area was first used for breast reconstruction in 1979. This tissue or "flap" was called the TRAM (Transverse Rectus Abdominis Myocutaneous) flap.

In the last two decades, the use of this tissue has become the gold standard in reconstruction with body tissue. The tendency to take less of the straight abdominal muscle ultimately resulted the development of the free DIEP flap (Deep Inferior Epigastric Perforator Flap). The feeding blood vessels running to the fat and skin through the straight abdominal muscles can be dissected free by splitting the straight abdominal muscle. So there is no need to take away the straight abdominal muscle.

Advantages

Post-operatively, there is no weakening of the abdominal wall or loss of function of the trunk muscles. Patients who have undergone DIEP flap reconstruction are usually able to resume their normal daily activities 4 to 6 weeks after the procedure.
Since the free DIEP flap has a longer vessel stalk, the shaping of the new breast with the abdominal skin and fat tissue will be easier and achieve a better aesthetic result.

Disadvantages

The disadvantages of this technique, like the free TRAM flap, are mainly microsurgical in nature: a prolonged operating time (approx. 7 hours unilaterally, approx. 9 hours bilaterally) and the risk of thrombosis (approx. 5%) and possibly complete loss of the flap (approx. 2%). It is a medium surgery with a rehabilitation period of 4 to 6 weeks. During this period, the patient will be more easily fatigued and will not be allowed to lift things (nothing more than a telephone book). On the abdomen there will be a scar from one hip to the other. The scar can usually be hidden.

Tissue from the gluteal region: the free 'S-GAP' flap (Superior Gluteal Artery Perforator)

In this technique, an ellipse of skin and fat is removed from the gluteal region or the buttock and transplanted to the thorax as a free flap and anastomosed by means of microsurgery in a similar manner. The free SGAP flap is usually used when there is not enough tissue at the abdominal wall. After all, the fatty tissue of the buttocks is of slightly lower quality in relation to the abdominal wall.

Nipple and areola reconstruction

When the technique of autologous breast reconstruction is used, a nipple and areola reconstruction will automatically have to be performed. It usually takes about four months for the new breast to take on its final shape.

The nipple is usually reconstructed under local anaesthesia with a small flap of skin from the flap in the place where the new nipple is to be formed. This will lead to new small scars on the breast in the vicinity of the newly formed nipple. However, these scars will be camouflaged by the tattoo of the areola.

Occasionally, the nipple can be reconstructed by transplanting part of the other nipple. Of course, this is only the case if it is large enough to take away a section. The areola is reconstructed by tattooing the areola region. This tattooing takes place about 1 to 2 months after the reconstruction of the nipple.