Breast cancer surgery with reconstruction, immediate or deferred

The development of new techniques and medical materials enable breast surgeons to create a breast of similar shape, texture and with characteristics of a non-operated breast.
What is a breast reconstruction?
Breast reconstruction after a mastectomy (removal of the same breast cancer or other disease) is one of the most current surgical procedures in plastic surgery and most gratifying for the patient. The development of new techniques and medical materials enable breast surgeons to create a breast of similar shape, texture and with characteristics of a non-operated breast.
Thus, breast reconstruction aims to:

• Recreate a natural looking breast including, if desired by the patient, the areola and nipple.

• Eliminate the need for filling prosthesis, enabling women to wear clothing that would not be possible without reconstruction (swimsuits, necklines, etc...)


•  Filling the gap and deformities left in the chest, restoring the body shape, improving quality of life and providing satisfaction and psychological well-being for the patient in a difficult and transcendental moment.

When and which patients can rebuild their breast?
Almost all women with mastectomies may be considered, from a medical point of view, candidates for breast reconstruction. In most cases when the breast is removed. The optimal candidate is one where the tumor has been completely removed during mastectomy. When the breast is reconstructed during mastectomy (referred to as immediate reconstruction technique), the patient wakes up from surgery with a suitable breast contour, avoiding the experience of seeing the amputated breast; the psychological benefit of this technique is clear.

In some cases however, the reconstruction may or should be postponed (referred to as delayed reconstruction technique). Some women do not feel comfortable talking about reconstruction, whilst trying to adjust to having been diagnosed with breast cancer. Other women simply do not want more interventions than strictly necessary to cure the disease. In other cases, the use of more complex reconstruction techniques make it advisable to delay the reconstruction, so as not to extend the intervention for too long. If there are associated medical problems such as obesity or hypertension, it may also be necessary to delay the reconstruction.

In addition, immediate reconstruction requires a close collaboration between the surgeon removing the breast and the plastic surgeon, as it requires the presence of both when operating the patient. This is not possible in hospitals where there is no plastic surgeon (for example community hospitals), a situation that makes it necessary to delay the reconstruction that will be performed in another center at a later date.

In either case, it is important to have clear and adequate information about the possibilities of reconstruction before being operated, in order to deal with the intervention in a positive way.


Risks of the Breast Reconstruction
Basically all women who have had a mastectomy (where one or both breasts have been removed) can undergo breast reconstruction. However, there may be certain risks that must be known before submitting to this procedure. These risks can be those of any surgery, such as bruises, pathological scars, or anesthetic problems which, although rare, should always be considered. Likewise, women who smoke should know that tobacco can cause healing problems and lead to a longer recovery period.

If reconstruction implants are used, there is a minimal chance of infection, usually in the first or second week after surgery. In some of these cases, it may be necessary to temporarily remove the implant, which can be placed back later. The most common problem associated with implants is capsular contracture, consisting of the organism forming an internal scar capsule around the implant that can make the reconstructed breast have a harder consistency than normal. This is no more than an exaggerated physiological response of the organism towards a body not recognized as its own. There are several methods to prevent this, such as massages in this area, the use of ultrasound or removal via surgery.

It should be clear that the reconstruction has no effect on the recurrence of the breast disease, and it will not interfere with either chemotherapy or radiotherapy treatment, if the disease comes back. It will not interfere with subsequent studies that may be needed during reviews. If your breast is reconstructed using implants and your surgeon recommends performing regular mammography’s, it is recommendable to have them done in a radiology center experienced in the use of radiological techniques for prosthesis.

Who performs the breast reconstruction and where?
As soon as a woman is diagnosed with breast cancer, she should get information about the possibilities of reconstruction. The surgeon performing the mastectomy, the oncologist and the plastic surgeon should coordinate to develop a strategy to converge the best possible result.

The plastic surgeon is the specialist who by training (specialist in Plastic, Reconstructive and Aesthetic Surgery), has the technical and aesthetic resources adequate to reconstruct a natural-looking breast. After assessing the patient's general condition, he will inform you about the most appropriate options for your age, health, physical and anatomical characteristics and future expectations.

Breast reconstruction is included in the Social Security benefits catalogue, as long as the hospital has a plastic surgery team. Most private insurers also include this type of intervention within their service catalogue.


Breast reconstruction techniques


There are several types of surgery to rebuild the breast:

1. Cutaneous expansion techniques:
it is the most common and consists of expanding the skin and subsequently placing prosthesis. After mastectomy, the surgeon places an inflatable balloon (expander) under the skin and chest muscle. Through a valve mechanism buried under the skin, a saline solution is introduced once a week, during several weeks until the expander is filled. Once the skin of the chest area has stretched enough, the expander is removed and replaced by a mammary silicone prosthesis or saline prosthesis, which will remain there. There are certain expanders which are designed in such way, that they can be maintained as final implants. Both procedures are performed under general anesthesia, with a short hospital stay of 24 to 72 hours. If the breast, which hasn't been mastectomized, is too big, too small or too sagged, it may be necessary to reduce, increase or raise it. It will be necessary to reconstruct the other in order to achieve a symmetrical result. The nipple and surrounding skin (areola) are reconstructed later, under local anesthesia and on an outpatient basis (without hospitalization). The prosthesis used in this type of reconstruction contains medical silicone, like many other materials used in other fields of surgery (testicular prostheses, facial implants, etc.). There is no proven link between breast cancer and the use of breast implants, and it is not linked to autoimmune and rheumatic diseases. Its use is approved in all European countries.

2. Techniques employing its own tissues:
these techniques use one’s own tissue to create a natural breast. They consist in the mobilization or transplantation of tissue from other parts of the body, such as the abdomen, back or buttocks (called autologous techniques or flaps). In some cases these tissues or flaps remain attached to its original location, retaining its blood supply, and are transferred into the breast through a tunnel that runs beneath the skin. According to the technique, it may or not be necessary to use an implant. In other cases, the tissues used to create the breast, are separated completely from its original site, usually the abdomen, buttocks or thighs, and are transplanted to the chest by connecting to the blood vessels in this area (free flaps). This procedure must be performed by a plastic surgeon with experience in microsurgery.

Regardless of whether the tissue is passed through a tunnel under the skin or transplanted, these techniques are more complex than those using skin expansions, leaving more scarring and the recovery period is longer than for implants. However, the aesthetic result is very superior, generally only one intervention is needed and the problems related to the implants do not exist (capsule formation, infection of the implant).

In some cases, when abdominal tissue is mobilized, there is the added benefit of improving abdominal contour (as if it were a cosmetic correction of the "belly"). This technique is also performed under general anesthesia, with a hospital stay of 4 to 7 days.

Results
The result after breast reconstruction is definitive and allows for a normal way of life. In some cases, the reconstructed breast may look firmer and rounder than the other breast. It is possible that the contour may not be exactly the same as before the mastectomy, and there may be some differences in symmetry to the non-operated breast. However, these differences are often only apparent to the woman herself, not being perceived by others.

For the vast majority of breast cancer patients, breast reconstruction is a complete image improvement, also providing a psychological balance that in many occasions was lost, returning to see a complete body. This will allow you to have a social, as well as a comprehensive sexual, life, and forget the illness that led to the reconstruction.