There are 2 main techniques in breast reconstruction:
Prosthetic Reconstruction, resorts to the use of silicone breast implants. This technique is simple and leaves no additional scar. The surgery is performed under general anesthesia and lasts about two hours. The mastectomy scar is used to create a pocket behind the major pectoral muscle to insert the implant. There are several types of implants. In breast reconstruction, I only use anatomical prostheses and sometimes asymmetric prostheses, as they give a more natural form to the reconstructed breast, and these implants are textured to reduce the risk of the formation of a periprosthetic capsula. An abdominal advancement flap is taken during the same procedure where abdominal skin is used to create a beautiful curve for the lower part of the breast, and to define the submammary fold. I rarely use expansion prostheses to stretch the skin, as this technique requires biweekly inflations of the implant for three months, and tends to weaken and refine the skin.
Breast reconstruction by implants is chosen over other techniques, when the remaining breast is not too large or too sagging, AND the chest skin is of good quality.
Breast reconstruction by implants is strictly contraindicated, where the chest skin is of poor quality, fixed or stretched. In these circumstances, the risk of exposure and infection of the implant is significant.
A second or even third intervention is needed, a few months apart to harmonize the contralateral breast and reconstruct the areola and nipple.
Autologous reconstruction uses the patient’s own tissues.
When the remaining chest skin after mastectomy is not enough and/or of poor quality, prosthetic reconstruction cannot be considered.
A tissue transfer or flap is the provision of good quality tissues, including skin, muscle and adipose panicle, with their feeder vessels. The flap can be taken from the back, abdomen or buttocks, and is transferred to the site of amputation.
A flap is a “muscular flap" if it is only composed of muscle, "musculocutaneous flap” when it is composed of muscle, fat and skin, and "cutaneous flap" if it is made of skin and fat.
A "pedicled flap" is a flap attached to its feeder vessels (pedicle), whereas a "free flap" is a flap where these vessels were cut for the flap to be reconnected to recipient vessels through microsurgery techniques.
The technique is chosen according to local and general conditions, and the desire of the patient.
Breast reconstruction by flap is much more complex than placing an implant. The scar will also be more significant, both in the reconstructed breast and in the flap donor site. However, when the breast is entirely reconstructed with the patient’s own tissues, without any prosthesis, the result is more natural and more stable over time.
The Latissimus Dorsi muscle is the largest muscle in the back, extending from the pelvis and from the last vertebra to the humerus at the shoulder joint. Functional consequences due to the removal of this muscle are negligible for adults.
In breast reconstruction, the surgeon generally takes a musculocutaneous flap (muscle, fat and skin). This flap can cover an implant at the receiving site. In some cases, where the morphology of the patient is adequate (i.e. the breast to reconstruct is small or medium, thick subcutaneous adipose panicle), this flap may be used alone, without a prosthesis.
The skin of the back used for the reconstruction of the amputated breast, called skin paddle, is shaped like a spindle.
The scar at the donor site can be oriented in different ways:
The surgery is performed under general anesthesia and lasts about three hours. The patient is hospitalized for an average of eight days. The procedure has negligible impact on the patient’s work and working out is possible.
The Rectus Abdominis muscle is a paired abdominal muscle extending along the midline, from the pubis to the thorax, and consists of two large parallel muscles. The abdominal skin paddle has the form of a horizontal spindle, extending the most between the navel and the pubis. Breast reconstruction by this musculocutaneous flap uses in general a single muscle.
This flap allows the reconstruction of a large breast with or without the use of a prosthesis. The closure of the abdominal donor area requires an abdominoplasty to refine at the same time the silhouette of the patient. The removal of the muscle also requires repairing the abdominal wall, using a thin prosthetic mesh to prevent the risk of postoperative evisceration, as there is often a flaw in the abdominal wall after the intervention
This procedure is a heavy and long intervention (lasting an average of 5 hours). The patient is usually hospitalized for 5 to 7 days.
This flap can be used in a free transfer (free TRAM or free DIEP), requiring a microsurgical procedure. In these cases, the surgeon takes less muscle (free TRAM) or even none (DIEP), and the parietal effects are less. However, this technique is longer, and heavier, requiring a stay in intensive care to monitor the viability of the flap, and the risk is greater.