More than 40.000 new cases of breast cancer are discovered each year in France. We know how devastating it is to be diagnosed with this illness. It is even easier to understand that for a woman, having breast cancer affects her femininity. Thanks to early tracking one can avoid many problems, however despite these check ups certain women will have to undergo partial or total removal of the breast. This is called a mastectomy. Breast reconstruction will then be proposed. Indeed for the last few years, this operation is an integral part of the treatment. It can be covered by health insurance, like any other reconstructive surgery. The best results are obtained when the breast reconstruction is immediate, but in most cases the reconstruction will be done later. Following mastectomy, the surgeon will work on the volume and shape of the breast. After a few months, when the breast acquires its final shape, the surgeon will reconstruct the nipple and the areola. In all these cases the surgical procedures require great competence.
BREAST RECONSTRUCTION TECHNIQUES
During breast reconstruction, the surgeon uses either implants or flap grafts using the patient’s own body tissue. Occasionally he will use a combination of the two. The surgeon will analyze the advantages and disadvantages of the various possibilities, and will only take a decision after discussion with the patient, whose needs (psychological conditions), skin tissue and muscle quality (anatomical conditions) will be taken into account.
RECONSTRUCTION USING AN IMPLANT
During general anaesthesia, the implant is placed under the pectoralis muscle. The outer envelope of the implant is made of silicone. The contents are either saline solution or silicone gel. Both have their advantages and disadvantages. If the remaining skin after the mastectomy is of good quality but not elastic enough to accommodate the volume of the implant, this can be solved in many cases by using an expander or a progressively inflatable implant. This is a silicone implant that can be filled with an increasing amount of saline over several months, through a small tube connected to a small inflatable chamber under the skin. This will slowly expand the skin until the size of both breasts match. The expander is then removed and replaced by a permanent implant.
1 – Leakage: An implant containing saline solution can often deflate, partially or totally. A surgeon will often recommend implants containing silicone gel, visually more attractive as well as more natural to touch. Their efficacy and safety has been repeatedly verified in recent studies.
2 – Capsular contracture: The implant can cause the appearance of capsular contracture. This is a normal physiological reaction where scar tissue formed around the implant thickens and the breast hardens. Corrective surgery can be performed to remove the contracture. If the contracture reappears, the type of implant can be changed. Except if the patient decides to preserve firm breasts. During breast reconstruction, the surgeon will often carry out a breast reduction procedure and lifting on the other breast, in order to correct asymmetry. Asymmetry can persist and increase over time. In any case, it is mandatory to consider a potential change of the implant (s) in the future.
RECONSTRUCTION USING A FLAP GRAFT
One can reconstruct a breast with flaps using the patient’s own tissue. The result in terms of both shape and consistency will be more natural. Skin, fat, and muscle, will either be taken from the back, the abdomen, or the buttock.
The latissimus dorsi flap
The disadvantage of taking tissue from the upper back is the inconvenience itself, as well the remaining scar. A combination of an implant is normally needed.
In the area that the tissue is taken from, pockets of clear serous fluid or lymphatic liquid called seroma frequently occur and will be drained in the weeks following the procedure.
The TRAM (transverse rectus abdominal muscle) flap
The main risk is a residual weakness of the abdominal wall. In all reconstructions using flaps, the recovery and healing process are longer. A reconstruction by implant lasts an average of two hours. Harvesting the flap and then reconstruct the breast, takes at least twice as long. For all flaps another risk is the partial or total loss of the flap especially for obese, smoking or high blood pressure patients.
The aesthetic result is evaluated at the end of the first year and then once a year.
In conclusion when breast cancer is diagnosed and the conditions of the patient allows it, it is possible to propose immediate reconstruction by implant and reshape the other breast at the same time. Final improvements can be achieved with further surgery, as well as nipple and areola reconstruction.
PARTIAL BREAST RECONSTRUCTION
Reconstruction after a partial mastectomy can be difficult because the breast is often deformed. Scars following tumor removal will modify the tissue (including the ‘safety’ margin) and generate contractions, which are often difficult to treat. For example it is practically impossible to perform conservative treatment on small breasts without major aesthetic deformities. An implant will then become necessary. A flap can be also used to replace scar tissue and regain shape and texture.
Fat injections or lipofilling, can also be used in breast reconstruction to improve the shape and volume and the eventual post radiotherapy lesions. Especially if the subcutaneous layer is very thin, we can start with adding fat to this layer and later proceed with implanting a prosthesis..
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