Breast Reconstruction

Reconstruction declares the dictionary, means “building a new according to the original model”. The dictionary definition is also valid in case of breast reconstruction. That is, we refer to constructing anew a breast that underwent partial or full mastectomy following the removal of a malignant tumor.

This is a complex operation, which demands high technical skills and expertise of the surgeon, and it is worthwhile that the patient be mentally prepared for the fact that it usually doesn’t end with a single operation. However, no doubt this is one of the highlights of plastic surgery. Not only because of the capability to create something out of nothing, as for the ability to repair and improve a body image and a mental status that were injured.

About 4,000 women are diagnosed each year in Israel with breast cancer – the most widespread malignant disease in the Western world. Besides chemotherapy and radiation, the main treatment for this disease is surgery to remove the malignant tumor. The extent of surgery varies, and it can range from removing solely the lump (lumptectomy), through the amputation of a breast quadrant (quadrant resection or quadrantectomy), to full amputation (mastectomy).

A mastectomy is dissimilar to an appendix removal surgery, although in both cases, a surgeon cuts out in the operating room diseased tissues from the body. The significance of mastectomy for the patient may be far-reaching and extensive, since it does have an effect on her sense of femininity and female sexuality as well as her self-perception. Additionally, it may turn coping with cancer, which is complex as it is, much more difficult.

This is the reason why many women choose to perform a breast reconstruction procedure, as well as the fact that the reconstruction procedure is included within the National Health Basket and that it is considered an integral and inseparable part of the treatment of the disease.

The reconstruction process may be performed during the mastectomy procedure (immediately after the breast surgeon completes the removal of the tumor, the plastic surgeon goes into action, while the patient is still anesthetized) or it can be executed many months afterward.

It is important to note that breast reconstruction does not reduce the cancer treatment options, it doesn’t diminish the treatments effectiveness, does not delay or interfere with the detection of cancer in case of a recurrent disease and it has no positive or negative effect on the prognosis (the disease healing forecast).

There exist several different surgical techniques for the reconstruction of an amputated breast, and they are separated into two main categories: an Alloplastic reconstruction (this is a reconstruction utilizing an artificial implant, such as silicone) and an Autologic reconstruction (this is a technique using the patient’s own body tissues, such as skin and muscles from the abdomenal area, the back or the buttocks).

The choice of the exact technique is given of course to the discretion of the patient and it depends of her medical data, the question of timing (some techniques are better suited for restoration during the amputation procedure while others are preferable in reconstructions performed after treating the disease), and the plastic surgeon’s gained experience in either method.

Breast reconstruction using abdominal fat tissues and skin is a long and complex surgery – but it is considered to be the reconstructive technique having the best aesthetic results.

This procedure has several advantages: the patient’s own body tissues are utilized, thus preventing the insertion of a foreign body into the breast; the reconstructed breast has a more natural feeling and appearance compared with a breast that has been reconstructed using an implant; in most cases, the reconstructed breast regains back sensation within 1-2 years; the reconstruction is maintained throughout many more years, it matures more naturally and it resembles the other breast; this reconstruction usually doesn’t demand additional operations in the following years; it hurts less than an operation using the abdominal muscles; unlike surgery that uses the abdominal muscle, in this procedure usually there exists no weakness of the abdominal wall or concerns regarding the development of a hernia; overweight women might consider the removal of fats from the abdominal area an advantage.

However, this procedure also has its drawbacks: it lasts longer than a reconstruction using implants (the operation duration is approximately 8 hours); the healing period is lengthier than that of a reconstruction utilizing an implant (still it is shorter than a reconstruction using the abdominal muscle); the operation involves creating another scar in the lower abdomen; the incidence of immediate complications following surgery is greater (although the amount of complications over the years is similar to that of a silicone implant); the surgery requires great expertise by the surgeon hence the few plastic surgeons willing to perform this kind of operation. Another disadvantage is the fact that in case the patient needs an additional breast reconstruction, she will not have the possibility to use this technique once again.

A breast reconstruction using abdominal fat and/or skin suits every patient who underwent full or partial breast amputation, patients who underwent a failed reconstruction using a silicone implant or a tissue expander as well as to patients with congenital breast defects. The operation is also suitable for women who have had radiation therapy (radiotherapy treatments) which damaged the healthy tissues of the breast or for woman who underwent a relatively large amputation (inasmuch as in these situations not enough skin tissue is left in order to perform a reconstruction using an implant). However, note that if the patient is expected to undergo additional radiation treatments, it is preferable to delay the reconstruction surgery until after the radiation treatments, since they may damage the reconstruction results.

It is important to take into account that a reconstruction performed using this technique is considered to be a complex procedure and a large operation, and is therefore only suitable for patients who beside cancer have no other significant diseases (such as a heart disease, severe asthma, etc).

Furthermore, this procedure cannot be performed on patients who underwent previous abdominal surgery (since the blood vessels the surgeon wants to transfer to the breast are encountered at the lower abdomen, and if they were injured during a previous operation, it will be impossible to use them). Finally, the procedure is only suitable for women with a sufficient amount of abdominal fat tissue – but not for women who are extremely overweight and obese (BMI>40).

It is important to remember that the reconstruction procedure is subject to the patient’s choice. She can choose to undergo the reconstruction procedure along with the mastectomy – and thus already at its completion, she will emerge from the operation room with a reconstructed breast, or she may decide to postpone the reconstruction’s performance for a later date. Clinical experience shows that there are clear benefits to performing an immediate reconstruction rather than a delayed reconstruction – both in the mental aspect and the physical aspect of the length of the scars and the skin quality of the reconstructed breast.

However, there are many patients who find it very difficult to contend with decision-making and the emotional burden accompanying the detection of cancer within their bodies, and they prefer to postpone the decision regarding the breast’s reconstruction after its amputation to the period following the completion of cancer treatments.

In any event, before making a decision regarding the operation’s performance, it is important to consult a plastic surgeon who specializes in treating this problem, and to discuss with him the various technique types, the advantages and disadvantages of every one of them, and the patient’s personal suitability for a specific kind of surgery. Consultation should be undertaken in parallel with the attending oncologist and the breast surgeon who will remove the tumor.

Likewise, it is imperative to discuss with the doctor in detail the possible results of the operation, so the patient arrives for surgery with realistic expectations and that she won’t find herself disappointed from the results.

Reconstruction by obtaining fat tissue and skin from the patient’s lower abdominal area is one of the procedure types which make use of self tissue deriving from the patient’s own body. This procedure is an improvement of an older technique, in which the patient’s abdominal muscle is used (TRAM), and it spares the complications associated with muscle usage.

The purpose of this procedure is to create a new breast instead of the one that was amputated, while using skin and sub-skin fat from the abdominal area. During the operation, the surgeon performs an ellipse-shaped incision at the lower abdominal area. Afterwards, he isolates the small blood vessels that nourish the fat and the skin and which penetrate the abdominal muscle. The abdominal tissue together with the blood vessels is transferred to the chest wall, and there, with the assistance of a surgical microscope, they are connected to blood vessels in the chest – while maintaining the continuity of blood supply. There are two surgical approaches to this matter, and each one of them is named after the blood vessel to be used by the surgeon:

 DIEP: Deep inferior epigastric perforator – the deep blood vessels are utilized.

 SIEP: Superficial inferior epigastric perforator – the superficial blood vessels are utilized.

The surgery is performed under general anesthesia, when the patient lies on the operating bed. During anesthesia, in the course of surgery, the surgeon will seat the operated patient in order to ensure that a good match has been achieved between the reconstructed breast and the healthy breast.

The surgeon will reconstruct the breast’s shape in accordance with the shape of the healthy breast. In case the reconstructed breast is larger or much smaller than the healthy one, amendments can be performed to the healthy breast at the same operation, in order to create symmetry.

At the completion of surgery, the surgeon wraps the reconstructed breast with a bandage and the abdomen with an abdominal belt. Sometimes drains will be left in the incision’s proximity (silicone tubes which drain the fluids that tend to accumulate at the operated area) and they will be removed by the surgeon after a few days.

Absolutely not. About 60% of the women who underwent mastectomy do not ask for any reconstructive surgery and they have quite a few reasons for doing so. Some women do not consider a reconstructive surgery to be a health requirement therefore they regard it as an “unnecessary” operation. Most of them feel they can manage without one breast, some are afraid that the reconstruction surgery might “trigger” the cancer (even though this is only superstition), there are those who think that the results of the reconstruction are not good enough thus it is pointless to go through the agony of further operations. And of course, there women whose health condition does not allow them to undergo breast reconstruction surgery.

The goal is to achieve an anatomical structure as similar as possible to that of the healthy breast, as well as symmetry between the two breasts. In many cases, in order to achieve symmetry, it is necessary to operate the second healthy breast as well.

Right after the amputation or at a later date. The advantage of an immediate reconstruction is that the woman awakes from the mastectomy with a new breast and she spares herself some of the trauma of breast absence, in addition to coping with cancer. The disadvantage of immediate reconstruction lies in the fact that it must be decided upon in advance, when coping with the disease has just begun. Moreover, at the initial treatment stage it is not always clear what will be the ongoing oncological treatment and whether chemotherapy or radiation treatments will be required. The radiations can mainly harm the cosmetic result of the reconstructed breast and that would be unfortunate. A belated reconstruction can always be executed: following the amputation surgery, at the end of the radiation treatments or completion of chemotherapy, even years after and always in accordance with the general health status.

Listen to yourself, find out what you want and what are your needs, there are several methods of breast reconstruction and the method should be adjusted and suited to your desires and needs. And of course not all women have the same needs. Some women want to look good when they’re dressed, therefore they will be satisfied with a padded bra, others will prefer a silicone implant underneath the skin, so that with an appropriate bra and clothes the new breast will look like the other breast, on the other hand some women desire the reconstructed breast to be as similar as possible to the healthy one, and this requires other types of reconstructions.

In addition to your will and your needs, you will also have to take into account medical considerations, such as your general health status and the chest’s tissues condition. Questions such as whether enough skin has remained after the amputation, what is the nature of the remaining skin, is it thin and glued to the chest wall, has that area been radiated, what is the condition of the second breast (too big, too small) or is a prophylactic mastectomy of that breast required – all of these will dictate the type of reconstruction you will be recommended.