During the past 20 yrs there has been a marked increase in the number of patients undergoing breast reconstruction following mastectomy. The technique utilised and the timing of reconstruction are determined on an individual patient basis.
Depending on the type of the ablative operation for the cancer of the breast and how extensive the surgery is, the reconstructive mode is either using tissue expanders ( alloplastic) or using tissue from a different area of the body (autogenous) to form a new breast mound. Both methods have specific indications and are applied accordingly. Following the breast mound reconstruction , a nipple-areola is constructed again using different techniques.
Another issue that arise is whether the patient receives immediate or delayed reconstruction. As a general rule,immediate reconstruction can be performed in patients with no advanced stage cancer. Because matching of the two breasts is usually not possible in one stage, a second operation is necessary to achieve symmetry. Surgical alteration of the opposite breast may also be required for achieving perfect symmetry some times.
Breast reconstruction. Techniques
a. Tissue expanders
b. Breast reconstruction with vascularised flaps
Α. Tissue expander procedure
At the first stage a tissue expander is inserted beneath the pectoral muscles and inflated as far as the overlying skin is safe considering its vascularity. Then at weekly intervals the prosthesis is further expanded. When the desired size is created, the patient waits for a couple of months so the tissues stretch and the expander is usually exchanged with a permanent prosthesis at another operation. However in certain clinical scenarios a single stage reconstruction without exchange at a second stage may be feasible.
Β. Autologous tissue breast reconstruction (flaps)
In case that x-Ray treatment follows the mastectomy, tissue expansion is somehow risky and autologous breast secondary reconstruction is indicated. Furthermore, when the contralateral breast is large and ptotic autologous tissue breast reconstruction offers a more natural ptotic reconstructed breast. The mostly used flaps for breast reconstruction are:
1. TRAM ( transverse rectus abdominis) flap, with or without microsurgical techniques
2. LD (latissimus dorsi) flap with imlant
3. DIEP (deep inferior epigastric perforator) flap
4. S-GAP ( superior gluteal artery perforator) flap
» TRAM flap is used in this patient for mastectomy reconstruction. Most patients have abundant tissue in the abdominal area that is utilised for breast reconstruction. Nipple reconstruction is usually done at a later stage for achieving better symmetry.(Dr. Spyriounis’s patient before operation)«
Possible contralateral breast operation and nipple reconstruction
It is possible in selected cases that a breast lift operation may be need for achieving symmetry. This is usually the case in very large contralateral breast. Nipple reconstruction is usually done at the same stage and tattoo pigmentation restores the areola colour.
Obese patients, smokers that have not given up smoking for at least 3 weeks before the operation, diabetics and patients that had previous abdominal surgery may suffer a high % of complications for both donor and recipient sites. Careful preoperative evaluation and thorough discussion with Dr Spyriounis will emphasize the possible complications and ways to avoid will be presented.