Breast reconstruction is a particularly important chapter in Reconstructive Plastic Surgery, having as a target the replacement of skin, mammary gland and nipple that have been removed during mastectomy.
The percentage of breast volume that is excised is related to the classification and size of the original tumour, while the main goal of reconstruction is the achievement of symmetry in both breasts.
Regarding the selection of breast reconstruction type, the main condition is to realize that each patient is different and unique. Consequently, reconstruction should be made on patient’s own personal characteristics based not only on her body frame, but also the mastectomy type.
Following mastectomy, the patient may choose:
The constant advancement of Reconstructive Plastic Surgery offers more than ever the opportunity to a patient who had mastectomy either due to cancer or as prophylactic breast mastectomy, proceeding with the optimal breast reconstruction.
Breast reconstruction following mastectomy IS NOT an aesthetic surgical procedure. The procedures of this type are performed in order to reconstruct the anatomy and symmetry. Such an operation is part of the disease treatment, that’s why the cost is covered by most of the private health insurances and EOPYY (Hellenic National Health System).
Besides, Breast Reconstruction following mastectomy, does not change only the physical appearance of the patient but also has a huge psychological impact, enhancing personal well being, both on a personal and family level, as well as improving self-esteem.
The proper timing for breast reconstruction, depends on the following:
For several women, immediate reconstruction (eg. Breast Reconstruction in combination with mastectomy), reduces the psychological impact that a patient may have due to the feeling of frustration on one hand, and on the other reduces the cost and discomfort undergoing two major operations at different time periods.
However, this does not mean that a patient cannot undergo Breast Reconstruction months or even years following Mastectomy (Delayed Breast Reconstruction).
For example, if the patient has started chemotherapy or radiation regimen, then usually Breast Reconstruction is postponed, until having completed those therapies.
Is there any “rule” regarding which type of reconstruction is the breast? What about immediate reconstruction considered as the safest, since it is known as “one and done”?
Quite often we discover “new” approaches, such as “one and done”. Although it sounds great and the specific treatment is the ideal choice for all women, “one and done” sometimes may be proven misleading, since more than 30% of women as described in the international literature, will need at least one more surgical procedure.
Of course, one step procedure, is a common surgical procedure performed with immediate use of implants, either solely, or in combination with Alloderm.
However, this surgical procedure is indicated in patients who meet certain conditions, such as patients undergoing prophylactic mastectomy (eg. BRCA +). In these cohorts, the possibility to need only one surgery are extremely high.
Regarding patients undergoing mastectomy following cancer, the following should be taken into consideration before selecting the surgical procedure “one and done”.
A key element for which the patient should be aware of, is that the final aesthetic result depends, to a large extent, on tissue thickness covering the implant.
Often, following mastectomy, the tissues that remain above the implant do not have adequate thickness in order to cover it fully, even if it’s placed under the muscle. Consequently, many patients have to deal with “rippling” post operatively, that is a visible breast implant creating “folds” that are visible on the skin.
A visible implant results in a dissatisfied patient, needing revision in order the implant not to be visible. This is usually treated with fat grafting and is one of the most common reasons that patients would like another operation.
Another element that should be taken seriously into consideration, is the probability of radiation following mastectomy. Radiation, of course, does not have contra-indications to Breast Reconstruction, but it increases the risk of complications and may affect the final aesthetic result.
Radiation and implants often do not react well if they are combined. We should remember that skin is affected from radiation and the presence of a foreign body under the skin, increases the risk of wound dehiscence, delayed healing and exposed implant.
Finally, an element that should also be taken into consideration, is Nipple Sparing Mastectomy, (NSM).
Nipple Sparing improves significantly the aesthetic results following breast reconstruction, especially if implants are used for reconstruction.
Patients who are not candidates for NSM or prefer not to spare the nipple, several times have less satisfactory results than a patient who has performed nipple sparing. Of course, cancer staging is also significant, since the treatment of the patient has a primary role.
Immediate reconstruction with flaps such as flaps from the abdomen (DIEP or TRAM) is extremely important and constitutes the “gold standard” in breast reconstruction worldwide nowadays, since they give the opportunity to the patients having exactly the same breast texture as their own, avoiding thus the psychological impact due to the feeling of frustration, since breast is considered the symbol of motherhood and femininity.
For patients preferring Breast Reconstruction with autologous tissues, TAG FLAP can also be easily performed in one stage, although in the literature, again, there are controversial debates about which patients have the best aesthetic results.
The main advantages in second stage Breast Reconstruction are the following:
It should be highlighted that a successful Breast Reconstruction does not affect the remaining therapies. However, in general, it should be avoided the irradiation of a reconstructed breast with implant, since that affects the quality of the result.
In case that the patient proceeds with Breast Reconstruction with implants, a potential infection may delay the initiation of other therapies, reducing their effectiveness. This is something that should ALWAYS be taken into consideration.
Finally, the consultation between team members involved in patient’s care (Oncologist Surgeon, General Practitioner, Plastic Surgeon, Radiotherapist, Pathologist) is necessary, in order to achieve the optimal result.
The final cost of breast reconstruction following mastectomy, depends on many different factors, such as:
The doctor will answer all the questions and will help you to find the most appropriate therapy, depending on your case.