Breast Reconstruction After A Mastectomy

The battle of medicine against cancer is gaining ground every day. Especially for breast cancer, the intense effort by researchers, the broad public information and the use of increasingly more effective treatments has led to prevention being more efficient and lessened the need for more extensive surgery. Nevertheless, the basis of any regimen is the surgical resection of the infected breast to some extent and/or form. In this article we will briefly discuss the serious and thorough help that plastic surgery can offer.

PROBLEMS AFTER A MASTECTOMY

The psychological effects of the amputation of the breast and the social phenomena that are incurred are well-known.

• The woman feels mutilated in such a delicate area, directly linked to her sense of femininity, and the shape of her body being so radically altered.
• The woman cannot dress the same any longer, especially light clothing and the participation in sports become particularly problematic. The use of specific implants, although of help, involves particular problems.
• The woman feels ashamed of other women and her partner and her role as a woman is profoundly disturbed.

NEWER VIEWS FOR MASTECTOMY RESTORATION

A decade earlier, the value of restoration after a mastectomy was controversial and not often performed. Today it is a perfectly acceptable form of treatment and more and more women seek it. In the United States, 20,000 breast reconstructions were performed in 1981 whereas 98,000 in 1984!
The reasons that make this operation be requested with increased frequency are:

• The development of better and safer techniques.
• An understanding on the part of the medical world, that surgery for the restoration of the breast does not cause metastases or conceals any local recurrence.
• The plethora, nowadays, of the many good outcomes.
• The persistence of women themselves for some form of restoration.

Previously it was performed only on women with a good prognosis (malignancy at the first stage). The intervention to save the woman’s life was thought to be enough! Nowadays, it is believed that every woman who is going to or has already undergone a mastectomy is theoretically a candidate for reconstructive surgery.

WHEN CAN THE INTERVENTION OF BREAST RECONSTRUCTION TAKE PLACE

Earlier on, it was felt that 1-2 years after surgery should have passed. This was done to give time for the classification of the disease based on histological and lymph nodes, for specific treatments to be implemented and the results to be evaluated and for the woman’s conscious request. Today, with the accumulation of more experience, most interventions for reconstruction are being performed just after the completion of the specific ancillary treatments, i.e. within 6-8 months after surgery. In recent years, based on specific new statistics, there is a growing trend for immediate restoration, which is performed during the same operation, immediately after the mastectomy, being ranked both during surgery and by the outcome of the biopsy.

OFFICIAL STATISTICAL DATA

It has been found that women with breast restoration regardless of the method used for the reconstruction (silicone implant, flap/escarpment or a combination of both), the specific ancillary treatments applied have not affected their efficiency. The survival rate is the same in women after a mastectomy whether they have undergone restoration or not. The prognostic significance of local recurrence is the same as metastases, and most women with local recurrence have other metastases. Since the frequency of local recurrence after a mastectomy is less than 10%, 9 out of 10 women will never face a problem of local relapse. And even in the most unfortunate cases, the quality of life for women with breast restoration is statistically significantly better than those without it.

THE OTHER BREAST

We must fully examine the other breast before proceeding with the infected one.

Restoration with the use of implants

It is the simplest method. It can be performed in cases where the mastectomy has left enough skin to accommodate the implant. Often this method is sufficient for a satisfactory outcome. Sometimes, however, the formation of a fibrous capsule around the implant can be problematic because it becomes harder and spherical. In such cases the breaking of the capsule through the use of hand pressure or the use of a minor intervention often helps.

The dilators

To overcome the problem of the formation of a fibrous capsule dilators are increasingly being used. These are small bags of silicone filled with saline, silicone or a combination of both. Placed under the skin that remains it is filled with a syringe with a very fine needle through a valve every 5-7 days so as to expand gradually. It is thus exploiting the elastic properties of the skin that expands slowly as during pregnancy. The skin expands so that the breast size is larger than originally desired and is left for about 6 weeks. Then the saline is being removed to achieve symmetry in size and with a small operation the valve is removed. At the same time the restoration of the nipple takes place. Lately, the use of the best implants of non-smooth surface has greatly reduced or even eliminated the fibrous capsule problems.

Reconstruction with flaps/escarpments

When the mastectomy has left the skin very stretched and thin, especially if the chest muscle has been removed then you need to somehow ''borrow'’ surrounding tissues for the reconstruction. Therefore, with special well-proven techniques we use, depending on the case-skin flaps or myodermal flaps (muscle and skin).
The most commonly used myodermal flaps are:

Wide dorsal muscle

The technique, although being described since 1980, has become the most common method of restoration lately. With this method we move skin from the back along with a part of the wide dorsal (which forms the ''wing' 'behind the armpit). If necessary, an implant can be placed underneath to add volume.

Rectus abdominis

It is the latest trend in the design of skin flaps. Part of the abdominal skin in excess, is moved along with one of the two rectal muscles to the breast area that is missing. Half of every rectal muscle can be also used for reconstruction on both sides. There is no need of a silicone implant and it can be used for large orifices or where the chest wall has been irradiated. The skin and the subcutaneous fat used is what we throw away during liposuction, the suture is low, just above the pubic, as in liposuction. It is indeed a magnificent intervention. However, it cannot be used on too thin or obese individuals or if any prior abdominal surgery has taken place that has affected the perfusion of the muscle.

Restoration of the nipple and the areola.

Earlier on it was considered a luxury in breast reconstruction, but nowadays it is a routine procedure. For the restoration of the nipple skin from the breast itself is taken and for the restoration of the areola a skin graft from the upper-medial thigh area. This usually takes place during the last stage of recovery. Suitable skin pigmentation improves colour matching.

Restoration after a partial mastectomy.

The removal of only the tumour or the relevant part of the breast in combination with radiation in selected cases, is more common nowadays, as an alternative to a modified radical mastectomy. In these cases the recovery is much easier, using skin flaps alone or with the use of silicone implants.

The results of breast reconstruction for the woman.

After the breast reconstruction has taken place, women feel less depressed about what has happened to them, they are more optimistic about life and feel better about themselves. Mastectomy gives the chance for life, breast reconstruction gives dignity and quality of life.