Breast Reconstruction

Reconstruction, according to the dictionary, means “rebuilding based on the original model.” This definition also applies to breast reconstruction. That is, it refers to the process of rebuilding a breast that has been partially or fully removed due to the excision of a malignant tumor.

Breast reconstruction is a complex surgery that requires high technical skill from the surgeon, and it is important for the patient to be mentally prepared for the fact that it usually does not end with a single surgery. However, there is no doubt that it is one of the highlights of plastic surgery. This is not only because of the ability to create something from nothing, but also because of the ability to repair and improve body image and mental well-being that may have been affected.

About 4,000 women in Israel are diagnosed with breast cancer every year – the most common malignant disease in the Western world. Aside from chemotherapy and radiation, the primary treatment for the disease is surgery to remove the malignant tumor. The extent of the surgery varies, from removing the lump alone (lumpectomy) to removing a quarter of the breast (quadrantectomy) to a full mastectomy.

Breast removal is not like appendix removal, although in both cases a surgeon removes diseased tissue from the body: the impact of breast removal on the patient can be profound, as it affects her sense of femininity, sexuality, and self-perception. In addition, it can make coping with the cancer diagnosis, which is already challenging, even more difficult.

This is why many women choose to undergo breast reconstruction, and the procedure is even included in the national health insurance basket as an integral and inseparable part of cancer treatment.

Breast reconstruction can be done at the time of the mastectomy (immediately after the breast surgeon removes the cancerous tissue, the plastic surgeon proceeds, while the patient is still under anesthesia) or can be performed many months later. It is important to note that breast reconstruction does not reduce treatment options for cancer, does not reduce the effectiveness of treatments, does not delay or interfere with detecting cancer recurrence, and has no positive or negative effect on prognosis (the likelihood of curing the disease).

Techniques for Breast Reconstruction

There are several different surgical techniques for breast reconstruction, which are divided into two main categories: alloplastic reconstruction (using an artificial implant, such as silicone) and autologous reconstruction (using the patient’s own body tissues, such as skin and muscle from the abdomen, back, or buttocks).

The choice of the exact technique depends on the patient’s preferences, medical conditions, timing (some techniques are more suitable for immediate reconstruction, while others are better for delayed reconstruction), and the surgeon’s expertise in each method. This text discusses breast reconstruction using fat or skin with fat from the abdomen.

Advantages and Disadvantages of the Procedure

Reconstructing the breast using skin and fat from the abdomen is a long and complex surgery, but it is considered the technique with the best aesthetic results.

The procedure has several significant advantages: it uses the patient’s own tissues, avoiding the introduction of a foreign body into the breast; the reconstructed breast has a more natural appearance and feel compared to one reconstructed with a silicone implant; in most cases, sensation returns to the reconstructed breast within 1-2 years; the reconstruction lasts longer and “ages” more naturally, similar to the other breast; it usually does not require additional surgeries in the years following the procedure; it is less painful than a surgery using abdominal muscle; and unlike abdominal muscle surgery, this procedure does not typically result in abdominal wall weakness or risk of developing a hernia. Women with excess abdominal fat may find it advantageous to use the fat from the abdomen.

However, this procedure also has disadvantages: it takes longer than reconstruction using a silicone implant (the surgery lasts about 8 hours); the recovery period is longer compared to implant reconstruction (though shorter than abdominal muscle surgery); the surgery creates an additional scar on the lower abdomen; the immediate complication rate is higher (though overall complication rates over the years are similar to those of silicone implants); and the surgery requires a high level of expertise from the surgeon, so only a few plastic surgeons perform this procedure. Another drawback is that if the patient needs further breast reconstruction in the future, this technique may no longer be an option.

Who is the Procedure Suitable For?

Breast reconstruction using abdominal fat and/or skin is suitable for patients who have undergone full or partial mastectomies, those who have had unsuccessful reconstructions using silicone implants or tissue expanders, and patients with congenital breast defects. This surgery is also appropriate for women who have undergone radiation (radiotherapy) that damaged healthy breast tissue or those who have had extensive mastectomies, where there is insufficient skin remaining for implant reconstruction.

However, it is important to note that if the patient is expected to undergo additional radiation, it is better to wait with the reconstruction until after the radiation treatment, as radiation may negatively impact the results of the reconstruction.

This procedure is considered complex and is suitable only for patients who, aside from the cancer, do not have other significant health conditions (such as heart disease or severe asthma). It is not an option for women who have had previous abdominal surgeries (since the blood vessels the surgeon wants to use are in the lower abdomen, and if they were damaged in previous surgeries, they cannot be used). Finally, the procedure is suitable only for women with sufficient abdominal fat – it is not recommended for women with severe obesity (BMI > 40).

Making a Decision to Undergo the Procedure

It is important to remember that breast reconstruction is a choice that belongs to the patient. She can choose to undergo reconstruction at the same time as the mastectomy – and thus wake up from the surgery with a reconstructed breast – or she can delay the reconstruction until a later time. Clinical experience shows that there are clear advantages to immediate reconstruction over delayed reconstruction, both in terms of emotional well-being and the physical aspects of scarring and the quality of the skin of the reconstructed breast.

However, many patients struggle with decision-making and the emotional burden associated with a cancer diagnosis, so they prefer to delay the decision on breast reconstruction until after the cancer treatment.

Before deciding to undergo surgery, it is important to consult with a plastic surgeon who specializes in the procedure, discuss the different techniques, the advantages and disadvantages of each, and determine the most suitable method for the patient. This consultation should also be done in parallel with the oncologist and the breast surgeon who will remove the tumor.

It is also important to discuss the potential outcomes of the surgery with the doctor, so the patient has realistic expectations going into the surgery and is not disappointed by the results.

Detailed Description of the Medical Procedure

Reconstruction using abdominal fat and skin is one of the procedures that uses the patient’s own tissue. This technique is an improvement on an older method that used the patient’s abdominal muscle (TRAM), avoiding the complications associated with muscle use.

The goal of the procedure is to create a new breast in place of the one that was removed, using skin and subcutaneous fat from the abdomen. During the surgery, the surgeon makes an elliptical incision in the lower abdomen. The small blood vessels that supply the fat and skin are then isolated, and the tissue, along with the blood vessels, is moved to the chest wall, where it is connected to blood vessels in the chest using a microscope to maintain blood supply continuity.

There are two surgical approaches, each named after the blood vessels used by the surgeon:

• DIEP – uses deep blood vessels (Deep Inferior Epigastric Artery Perforator).
• SIEP – uses superficial blood vessels (Superficial Inferior Epigastric Artery Perforator).

The surgery is performed under general anesthesia while the patient is lying on the operating table. During the surgery, the patient is positioned to ensure proper symmetry between the reconstructed breast and the healthy one.

The surgeon will reconstruct the shape of the breast according to the healthy breast. If the reconstructed breast is significantly larger or smaller than the healthy one, adjustments can be made to the healthy breast in the same surgery to achieve symmetry.

After the surgery, the surgeon will dress the reconstructed breast with a bandage and the abdomen with a girdle. Drains may be placed in the area to collect any fluid that may accumulate, and these will be removed after a few days.

Does Every Woman Who Undergoes a Mastectomy Have Reconstruction Surgery?

Not at all. About 60% of women who undergo mastectomy do not request reconstruction surgery, and there are many reasons for this. Some women do not see reconstruction as a necessary health procedure and regard it as “unnecessary.” Many feel they can manage without one breast, while others fear that reconstruction may “trigger” the cancer (even though this is a superstition). Some believe the results of reconstruction will not be good enough and prefer not to endure the additional surgery. There are also women whose health condition does not allow for reconstruction surgery.

What Can Be Achieved in Surgery?

The goal is to achieve an anatomical shape that is as similar as possible to the healthy breast, along with symmetry between both breasts. In many cases, in order to achieve symmetry, surgery on the healthy breast is also required.

When Can the Reconstruction Be Done?

It can be done immediately after the mastectomy or at a later date. The advantage of immediate reconstruction is that the woman wakes up from the mastectomy surgery with a new breast, saving her from some of the trauma of breast loss, in addition to dealing with the cancer. The disadvantage of immediate reconstruction is that it must be decided in advance, at a time when the patient is just beginning to cope with the disease. Additionally, at the initial treatment stage, it is not always clear what the future oncological treatment will involve, and whether chemotherapy or radiation will be required. These treatments (especially radiation) can affect the cosmetic outcome of the reconstructed breast, which is unfortunate. Delayed reconstruction can be performed at any time after

Breast Reconstruction with Silicone
Silicone, the same material used for breast augmentation, was re-approved in 2008 by the U.S. Food and Drug Administration (FDA). There are several types of silicone used in breast reconstruction surgeries: silicone gel implants, tissue expanders filled with saline (as the name suggests, they gradually stretch the tissue), and a combined implant, where part is made of silicone gel and part is filled with saline.

Types of Silicone Implants Used in Reconstruction

There are several types of implants: round, flat, high profile, and anatomical in various sizes and shapes. In reconstruction, unlike augmentation, there is a preference for anatomical implants, as they more closely mimic the natural shape of the breast. Due to the higher risk of capsular contracture (hardening around the implant), it is advisable to use implants with higher cohesiveness that maintain their shape (form-stable) rather than soft, round implants. It’s important to discuss with the plastic surgeon the different implant types to find the most suitable one based on body structure, skin quality, and chest shape.

When Can Silicone Gel Implants Be Used?

In immediate breast reconstruction following mastectomy, the tissue expander phase can be skipped if the surgeon can perform a skin-sparing mastectomy or even preserve the nipple (subject to the oncologist’s approval). This allows for enough skin to reconstruct the breast to its current size or even larger, all in a single surgery. In this case, it is usually preferable to add an “Alloderm” implant, which helps stabilize the implant and reduce tension on the skin. After a standard mastectomy, there is usually a loss of skin and breast tissue, making it impossible to directly insert a silicone gel implant. In these cases, a tissue expander is placed first, followed by a permanent silicone implant in a second surgery.

How Does a Saline Tissue Expander Work?

A tissue expander is made of a silicone bag with a valve through which saline solution is injected. The expander is inserted under the skin during surgery, and the valve can either be on the bag itself (identified by a magnet) or located farther away, hidden under the armpit. The purpose is to gradually expand the tissue beneath it, similar to how the skin of the abdomen stretches as a fetus grows. After the skin has been sufficiently stretched over a few months, another surgery is required to replace the tissue expander with a permanent silicone gel implant.

Should a Combined Implant Be Used?

A combined implant, partially filled with silicone gel and partially with saline, is designed to avoid the need for a second surgery to replace the expander with a permanent implant. However, this method doesn’t always work, and there is often still a need to replace the combined implant with a permanent one. Combined implants are more prone to complications and typically do not provide as natural an anatomical shape as permanent implants.

Disadvantages of Using Silicone

• Aesthetic result: The reconstruction is often fuller at the top, positioned higher on the chest, harder than a natural breast, and doesn’t move in the same way as the natural breast, making it different from the opposite breast.
• Complication rate: About 20% of cases require additional surgical intervention due to complications.
• Long-term results: After 5-7 years, the result often “deteriorates,” and a revision surgery may be necessary.
• Asymmetry: Because the reconstructed breast remains upright and firm, adjustments are often needed to the natural breast. Women with larger-than-B cups may never achieve perfect symmetry between the breasts.

Possible Complications from Silicone Implants

• Capsular contracture (hardening around the implant) occurs in 20-50% of cases.
• Wound dehiscence and exposure of the expander during saline filling, especially in breasts that have undergone radiation therapy.
• Implant or expander rupture.
• Visible asymmetry between the reconstructed and natural breast.
• Shallow or uneven filling: In some cases, the implant may not fully fill the void left by the mastectomy, resulting in depressions around and above the implant.
• Pain: There may be pain during saline injections, or sometimes chronic pain in the breast or around the valve. This is more common in breasts that have received radiation.
• Infection risk: Due to the presence of a foreign body, infections are more common in radiated breasts.

Anesthesia Used

All breast reconstruction surgeries are performed under general anesthesia.

What Happens During Surgery?

The surgeon marks the area for the expander/implant placement while you are sitting or standing. Afterward, an incision is made under general anesthesia, and the tissue expander or implant is inserted. In some cases, the surgeon may also lift the abdominal skin towards the reconstructed breast to create additional skin folds, which help to achieve a more natural breast shape (as opposed to the “half-sphere” look of a silicone implant). The breast is then bandaged tightly to secure the implant in place and minimize the risk of fluid accumulation around the implant. In most cases, a drain is left in place for 2-5 days.

Post-Surgery Recovery

This type of surgery does not require a hospital stay longer than 24 hours. Stitches are removed 10-14 days after surgery, and the process of gradually inflating the expander with saline begins 2-3 weeks post-op. You can return to work a week after surgery (without the breast being fully reconstructed yet). Physical activity should be avoided for at least a month.

Immediate Reconstruction with Permanent Implant

In cases of immediate reconstruction with skin-sparing mastectomy, it is possible to use a permanent silicone implant. An anatomical implant is typically recommended in these cases, and adding Alloderm (a dermal matrix made from processed human skin) helps to position the implant and reduce the likelihood of capsular contracture. Studies suggest that Alloderm may also reduce the frequency of complications associated with implant placement.

Tissue Expander Timeline

The main function of the expander, the inflation process, generally begins 2-3 weeks after surgery, with saline injections occurring once or twice a week. The amount and frequency of saline injected depend on the patient and her tolerance for pain (larger volumes are more painful). The process ends once the breast reaches the desired size (which varies depending on the implant size). After reaching the desired volume, the skin is left for 2-6 months to adapt to the new volume before the permanent implant is inserted in a second surgery. Recovery from this surgery usually takes between 3 days to a week.

Advantages of Using Silicone

• Insertion through the original mastectomy scar – This reduces the need for additional incisions.
• Simple and quick surgery – Generally, patients can go home the same day or the day after surgery.
• Options if the reconstruction fails – If the reconstruction fails, there are still other options, such as flap reconstructions.
• Better symmetry in bilateral reconstructions – In a double mastectomy, silicone implants tend to create more similar breasts compared to unilateral reconstructions.

Disadvantages

• Suboptimal aesthetic results – The reconstructed breast may appear firmer, higher, and less natural compared to the opposite breast.
• Complications – A significant number of patients will require additional surgeries due to complications such as capsular contracture, infections, or implant rupture.

In conclusion, silicone breast reconstruction offers a viable and commonly used solution for restoring the breast after mastectomy, though it comes with both benefits and risks. It is essential to discuss all options, including potential complications and aesthetic expectations, with a skilled plastic surgeon to determine the best approach for each patient.