Options of breast reconstruction by a plastic surgeon
Increase in quality of life thanks to breast restoration.
The number of new cases of breast cancer is increasing: Currently, 5,000 women in Switzerland and 57,000 women in Germany are diagnosed with a mammary carcinoma each year. This means that one in ten women will be affected over the course of her life.
In most cases of breast cancer, treatment begins with the surgery to remove the tumour and the examination of the associated lymph glands in the armpit on the same side. The goal is currently to conserve the breast in more than 70% of cases. In most cases, i.e. in approx. 80% of all female patients, the tumour can be removed while conserving the breast.
The decision whether the entire breast, either only glandular/adipose tissue (skin sparing, subcutaneous mastectomy) or complete including the skin above (ablation), the areola and the nipple has to be removed depends on tumour size, whether the lymph nodes are affected and metastases have formed. Breast removal is necessary if there are already several tumour centres in the same breast or the ratio between tumour and breast size is unfavourable, e.g. if a large tumour has occurred in a small breast. The breast should also be removed if a large-scale precancerous stage has been diagnosed. In case of necessary breast removal, the affected women can be offered an immediate or later restoration of the removed breast.
There are many criteria for the reconstruction of the female breast. The options and risks of breast reconstruction should be discussed with the patient already prior to breast removal. Both the technique and the time of reconstruction form a major part of this informed consent discussion with the surgeon, who should be experienced in both the reconstruction with autologous tissue and with implants, as well as in the combination of both methods.
As already mentioned above, both primary breast restoration, i.e. at the same time as breast removal, and secondary breast restoration e.g. following chemotherapy and/or radiation therapy, are possible. Immediate reconstruction primarily depends on the tumour type (classification), fear of amputation, general medical condition, age and expected chemotherapy or radiation therapy.
Generally, reconstruction using autologous tissue and restoration using a silicone implant, in consideration of the individual situation, can be considered solutions of equal value. Both procedures have their benefits and drawbacks. In breast restoration with autologous tissue, the surgical effort is somewhat higher and an additional scar will usually develop in the donor region of the autologous tissue. On the other hand, some patients have described a more natural breast feeling. A drawback over the long-term cause an be a reduction of the “new” tissue, which may require additional surgery.
Using silicone implants is the quicker option thanks to the shorter duration of surgery and the use of “foreign material”. Complications can also arise here, however, such as encapsulation of the implant, so-called capsule fibrosis. An advance measure to counter this is selecting the right implant coating. Most of my patients are overall highly satisfied with the new generation of implants and less often describe the sensation of a foreign object compared to previous generations of implants.
In both cases, the goal is to regain shape and size of the breast, to reconstruct all structures and to re-establish colour, texture and symmetry. The technique is always selected on an individual-case basis, depending primarily on the tissue condition of the affected breast, the breast shape, the scope of the defect after the mastectomy, the potential donor sites (for reconstruction with autologous tissue) and potential radiotherapy.
Once the decision has been made in favour of reconstruction using an implant, the first step is usually to stretch the healthy tissue with a variable expander (dummy). A permanent silicone implant can then be inserted after two to three months. The fourth generation of silicone implants is currently in use, featuring a special, non-liquid (cohesive) gel and a completely tight multi-layer shell. Various shapes (oval, round, anatomic) and different height profiles are available. As a result, the implant can be chosen individually based on the needs and the anatomy of the patient. The implants are offered with a smooth, roughened surface and with a special Microthane® (micro-polyurethane foam) coating.
Potential complications of restoration using an implant are the development of capsule fibrosis or the rotation (twisting) or dislocation (moving) of the implant. Capsule formation around an implant is normal up to a certain degree, since the body’s immune system will recognize the implant as a foreign boy and “encapsulates” it. The capsule will often harden significantly after a few years, however, causing significant discomfort. Patients will then report pain and an aesthetically unacceptable outcome. In most of these cases, renewed surgery to replace the implant will be necessary. This should be avoided. Because following cancer in particular, the breast tissue will usually already be scarred due to previous surgery. Immediately after irradiation, the tissue is also very much at risk of capsule fibrosis, so that the earliest recommended time for use of an implant is three months after completion of radiation therapy.
Generally, the following applies: The patient should always obtain detailed advice in advance, also regarding potential complications, from a specialist in plastic-reconstructive and aesthetic surgery who is mainly active in breast surgery. Today still, much depends on who the “initial adviser” is. An optimal consensus should be achieved between specialists, such as the GP and the plastic surgeon or, at the breast care centre, between the gynaecologist and the plastic surgeons, so that the patient does not experience any uncertainty regarding the surgical technique and the timing of surgery.
You can arrange an appointment for a consultation with us at any time.