Breast Reconstructıon

The most common type of cancer seen in women worldwide is breast cancer. According to research, 1 out of every 8-9 women suffer from breast cancer. Because the breast is the most distinct organ in the appearance of a female, breast cancer is one of the greatest traumas that a woman can experience in her life. The removal of a breast profoundly affects most women’s psychologies. Some feel deficient as a woman, some feel ugly, and some feel diseased for a lifetime. It is observed amongst women suffering from the loss of a breast numerous other conditions such as depression, loss of libido, disordered body perception, anxiety regarding the recurrence of the illness, and difficulties in finding suitable clothes.

Developments in medicine have enabled the reconstruction of breasts that are very similar to a natural breast. Breast reconstruction is a new start to life for most women. Patients to whom breast reconstruction has been applied have more compliant family relations and sexual lives. Breast reconstruction also enhances the psychological well being of patients, facilitating their fight against cancer. From this perspective, breast reconstruction surgery is not an aesthetic operation, but a repair (reconstruction) operation. In other words, it is the replacement of an organ lost due to the disease. In developed countries, breast cancer is treated by a team of experts consisting of a general surgeon, plastic and reconstructive surgeons, medical and radiation oncology specialists. This team evaluates the patient before the operation and determines the most appropriate treatment option.

What is the correct timing for breast reconstruction?
Breast reconstruction can be performed on almost all women who have lost their breasts due to breast cancer. Breast reconstruction can be carried out simultaneously with the removal of the cancerous breast, or afterwards in a delayed fashion:
• The cosmetic outcomes of simultaneous (immediate) reconstruction are much better. Simultaneous reconstruction is performed most commonly in the case of early stage cancer. The biggest advantage of early repair is the reconstruction of the breast in a patient whose breast has just been removed while protecting the overlying skin. Thus, it is ensured that the patient will experience less psychologic trauma caused by removal of the breast.
• In some conditions, there may be reasons to wait. In that case delayed reconstruction is performed. For example, some patients do not wish to undergo another operation. Some find it difficult to accept the diagnosis of cancer, and they cannot think of the alternatives of breast reconstruction. Some others may be advised by their surgeons to wait. Patients with obesity, hypertension, and smoking may be also advised to wait for some time.

What are the stages of breast reconstruction?

Breast reconstruction consists of 3 stages:

1. Construction of breast tissue:
A few operations are needed to achieve the appearance of a natural breast. The first operation is the construction of breast tissue, which is the most complicated.

2. Reconstruction of the nipple and areola:
The second and easier operation is the reconstruction of the nipple and the areolar area (the dark area around the nipple). This procedure can be performed under local anesthesia. The nipple is reconstructed from the surrounding tissues. The colored area around the nipple can be reconstructed by a tattoo, or skin grafts harvested from the other breast or the groin.

3. Achieving symmetry between the breasts:
When a unilateral (single sided) breast repair is performed, the reconstructed breast should not be expected to be symmetric to the other breast. This is especially true when the other breast is large or sagging. In that case, operations may be performed on the healthy breast to achieve symmetry. These operations may include reduction, lifting, or enlargement of the other breast.

Reconstruction of Breast Tissue:

Reconstruction of the removed breast is generally performed through two methods:

  1. A. Breast reconstruction with an implant (using a breast prosthesis)
  2. B. Breast reconstruction with an autogenous tissue (by using the patient’s own tissues)

The selection of the method depends on the following criteria:

• When the reconstruction is to be made
• General health status, age, and body characteristics of the patient
• The characteristics of the breast removal (mastectomy) procedure
• Whether radiotherapy is applied to the patient
• The condition of the other breast
• The patient’s preferences
• Surgical experience and talents of the plastic surgeon

  1. A. BREAST RECONSTRUCTION WITH IMPLANT:

There are 2 types of permanent breast implants based on their shapes:

1. Round Implant: These implants are not generally preferred in breast reconstruction.

2. Anatomic (Teardrop) Implants: Anatomic prostheses are preferred in breast reconstructions since the whole breast has been removed. The outer lining of these prostheses consists of silicone. They are either filled with silicone gel or liquid (saline).

In some of the breast implants used in breast reconstruction, both silicone gel and saline are combined. There are two cavities in these implants. The outer 35% is filled with silicone gel. The inner 65% is filled with saline (salty water) by an injection through a port. These prostheses are used in patients who will undergo radiotherapy. If there are no deformations in the prosthesis after radiotherapy, the port can be removed and the implant will be converted into a permanent one. The reason for the presence of a silicone gel in the outer lining is to provide a tissue and feeling most similar to breast tissue. In saline filled implants, vibrations may be perceived in the chest wall. Also, they react more quickly against hot and cold. Therefore, saline filled implants are preferred less frequently. The consistency of silicone gel is close to the breast tissue.

Breast reconstruction via implant can be performed through the adoption of two methods:

  1. Simultaneous implant based breast reconstruction
  2. Staged (two sessions) implant based reconstruction
  1. Simultaneous Implant Based Breast Reconstruction:

This method includes the reconstruction of the breast using either permanent or temporary prostheses, simultaneous with mastectomy (removal of the breast).

  1. Breast Reconstruction (Immediate) with Permanent:

If the patient will not receive radiotherapy after mastectomy (removal of the breast) a permanent implant is inserted during the same session. Depending on the stability of the prosthesis, another operation will not be necessary.

  1. Repair with Temporary Implant:

If the patient is expected to receive radiotherapy after the mastectomy (removal of the breast), a temporary implant will be inserted during the same operation. The biggest advantage of the temporary implant is to constitute a volume in the breast during radiotherapy. When a temporary implant is not inserted into this area during radiotheraphy, the breast will heal like a flat wall over the chest. Radiotherapy will make this area even flatter, and it will later be very difficult to expand this area and insert an implant. This will leave the patient with a single alternative, autologous (using the person’s own tissues) breast reconstruction. On the other hand, when a temporary implant is inserted, after radiotherapy the temporary implant can either be exchanged with a permanent one or breast reconstruction can be completed with the patient’s own tissues. In temporary implants, the implant can be inflated with the insertion of serum through its port, or the volume of the implant can be altered during radiotherapy for better reception of the beams. 6 months or 1 year after the radiotherapy is completed, the damage to the tissues caused by radiotherapy will heal and the temporary implant can be exchanged with a permanent one. While inserting a permanent implant, the procedure can be supplemented with fat injections. In some conditions, if the temporary implant is a combined implant (including silicone gel and serum), the implant port may be removed and converted into a permanent implant. However, it is necessary that radiotherapy has not created a significant deformity on the skin. If extensive damage due to radiation has formed on the patient’s skin and muscle (this differs based on the location of the tumor, dosage received, and the patient’s reaction to treatment), some problems may be experienced during the conversion to the permanent implant. In that case, the temporary implant is removed and autologous breast reconstruction is performed.

  1. Staged (Two Sessions) Implant Based Reconstruction:

This method is often preferred in patients whose breasts have been removed before without any reconstruction. In this procedure, a tissue expander (baloon) is inserted during the first session, then in the second session reconstruction is carried out with either an implant or the patient’s own tissues. In the first session of staged repair, a tissue expander is placed into the breast area. The tissue expander is like a balloon, when inflated volume is supplied to the breast. After a waiting period of 3-6 months, the tissue expander is removed and reconstruction is carried out with a permanent implant or the patient’s own tissues.

Do prostheses have risks?

In breast reconstruction with implants, because a foreign substance is inserted into the body, there are rarely occuring risks:
• Infection
• Silicone leak or implant deflation
• Loss of the natural breast appearance due to the development of hard tissue around the implant

However these complications are rare in implants produced with the current technology.

Do implants have a lifespan?

The lifespan of breast prosthesis is around 15-20 years. Therefore they need to be exchanged when the time comes. In addition to the lifespan of the prosthesis, body shape also changes. In the case of gaining or losing weight, or deformation in the breast weight, the old implant is removed through the old scar and a new implant is inserted.

Can breast implants explode?

Breast implants do not explode by any pressure, lying on them, or seat beat compression. They tear up when they sustain a sharp or penetrating injury. This condition is not harmful. Currently used silicone gels are 4th generation FDA (US Food and Drug Administration) approved gels. Even if the susbstance inside explodes, it does not leak into the body. Tearing of the implant can be detected via ultrasound. These events do not lead to or trigger cancer.

  1. REPAIR WITH AUTOGENOUS TISSUES:

Autogenous (patient’s own) tissues are more similar to breast tissue in their content. Thus:

• Their physical behaviour is more similar to a natural breast

• Return of sensation is better compared to implants

• In time, the scars fade and the tissues used soften, which increase the patient’s satisfaction

• Their response to weight gain and loss is like a normal breast. Thefore, if there is excessive weight gain or loss, or sagging due to age after breast reconstruction, there will be a better symmetry between the two breasts.

• It does not pose an obstacle to radiotherapy or chemotherapy applications.

Breast reconstruction using the patient’s own tissues is a more complicated operation that requires more surgical experience. The autologous tissue (patient’s own tissues) can be taken from various areas of the body:

• The skin, fat tissue under the skin, and one of the muscles on the front part of the abdominal wall can be transferred by pedicled or free tissue transfer techniques to reconstruct the breast tissue. An aesthetic abdominoplasty operation is performed at the same time.
• The muscle and the overlying skin, located on the side of the back can be transferred by pedicled or free tissue transfer techniques to reconstruct the breast. In this method, the resultant scar is often hidden under a bra.
• The skin and the underlying fatty tissue on the buttock or leg can be transferred with free tissue transfer (microsurgical methods) to reconstruct the breast. When the breast is reconstructed using free tissue transfer techniques, the fatty tissue under the skin is completely separated from the abdomen, back, or buttock area along with the feeding blood vessels. Then these vessels are tied to the vessels in the recipient area: this is necessary for survival of the transferred tissues. The surgeon performing these operations needs to be experienced in “microsurgery” because the connection of these vessels to each other is possible only under the microscope.

Can breast reconstruction operations be combined with fat injections?
Breast reconstruction operations can be sometimes combined with fat injections. While fat injection can be performed simultaneously with the insertion of a new implant, it can also be performed later to improve the results of a previously inserted implant. Fat injection may be added to improve the aesthetic results of a previous autologous breast reconstruction. Fat acts as a camouflage in breast reconstructions. Especially in thin patients, the prosthesis and skin may be very close to each other, leading to the palpation of the implant immediately under the skin. The skin may also lose thickness after receiving radiotherapy, making the posthesis more prominent. In order to decrease the prominence of the prosthesis, or treat problems such as depressions on the surface, and to attain a softer and more aesthetic appearance, fat is harvested from the abdomen or the back, using a needle. These fats are processed in the operating room and injected to areas where they are needed.

How is recovery after the operation?
After the operation, the patient may experience pain which can be managed with painkillers.
The patient needs to stay in the hospital for 2 or 5 days due to the type of operation.
The drains, which prevent the accumulation of blood at the operation area, are removed in a few days after the operation.

Will the patient regain sensation after breast reconstruction?
The patient does not regain a normal sensation with breast reconstruction. However, over time some sensation will be regained. Most of the scars will fade in time, however this may require as long as 1-2 years and the scars will not disappear completely.

Does breast reconstruction have any effect on cancer formation or its treatment?
Breast reconstruction does not have any effect on cancer recurrence or the patient’s prognosis. Also, reconstruction does not impede other therapies (radiotherapy and/or chemotherapy). During the follow up, periodic mammography or other radiologic studies can be performed easily.

Does breast reconstruction prevent the treatment of other cancers?
The patient can receive chemotherapy and/or radiotherapy both in autogenous and implant reconstruction. Breast reconstruction does not interfere with other treatments.

Is it possible to complete the radiotherapy during breast reconstruction?
Some centers, in suitable patients patients, apply “single dose radiotherapy” during the operation after the removal of the breast. Because these patients will not receive radiotherapy after the operation, a permanent implant will be inserted. In other words, the patient receives radiotherapy without waking up from the operation, and the implant is inserted during the same operation.