Breast plastic surgery after mastectomy (breast reconstruction). Techniques used for breast reconstruction after mastectomy Mammoplasty after mastectomy
Reconstruction of the mammary glands after a mastectomy is aimed at restoring the previous appearance of the breast and is carried out at the request of most women who have undergone surgery. Giving preference to this method, the patient, first of all, seeks to restore femininity and beauty in order to feel full again and start a new life after a major breast removal operation.
Breast plasty after mastectomy is a safe and highly effective manipulation, which is aimed at restoring the natural shape and size of the breast. This step is very important for women who have lost their breasts as a result of oncology (cancer, sarcoma), any pathologies (purulent process with gangrene), or due to serious injuries. Breast plastic surgery helps to restore both the physical and emotional state of a woman. After the procedure, it will be possible to wear clothes with a deep neckline again, sunbathe on the beach, etc. Visually, the artificial breast will have the same shape as the real one, but it will be devoid of sensitivity.
Women who are psychologically ready to undergo a full course of treatment and are absolutely confident in the correctness of such a decision can agree to mammoplasty. An important nuance is the absence of contraindications for surgical intervention, as well as diseases and pathologies that can interfere with the rehabilitation process and cause negative consequences.
Mammoplasty can be performed immediately after amputation of the mammary glands, or after some time, after the wound has healed and the body has recovered. It should be emphasized that the success of the operation will largely depend on the psychological readiness and emotional state of the patient. It is very important that the doctor explains to the woman in advance that the new breast may initially cause some discomfort, and in general, mammography will not give an impeccable result, since lines from surgical incisions will remain on the breast and in the donor sites after surgery.
Breast prosthesis after mastectomy
Reconstruction of the mammary glands after a mastectomy is a serious operation that allows you to artificially restore the shape and original appearance of the breast after amputation. Sometimes several procedures are required to obtain the desired result. Reconstruction can be done at the same time as mastectomy surgery while the woman is still under anesthesia, or later, some time after surgery. If a patient needs chemotherapy, doctors prefer to delay the procedure. Complications after breast reconstruction are extremely rare, most often they are infections, scars, bleeding.
Breast prosthesis after a mastectomy is necessary in order to "fill the void." Before such an operation, the surgeon clearly determines the size of the implant, the place of the future incision, and outlines the contour depending on the anatomical features of the patient's body. Prosthetics is the only method that allows you to restore the shape, original appearance and size of the breast as accurately as possible.
Dentures can have a different shape and are made of the following materials:
- silicone (the closest to the natural appearance of the breast);
- polyurethane foam;
- foam and fibrous filler (such "lightweight" prostheses are recommended to be introduced at the end of the recovery period, since they are considered the most convenient for physical activity).
Ideal prostheses should exactly match the appearance of real mammary glands, both in shape and in weight. Modern methods of surgery make it possible to make cosmetic sutures barely noticeable. Prostheses can be installed through different surgical approaches, the choice of places for incisions depends on the decision of the operating surgeon.
Modern breast implants are pouches filled with silicone elastomer or saline. As for the technique of inserting implants, it is quite simple: empty bags are inserted through small incisions in the skin and filled with a solution.
Restoration of breast nipples is a separate issue that requires a competent approach. The patient may prefer artificial nipples made of polyurethane and as close as possible to real ones in consistency, shape and color, which are attached to the breast with small suction cups. Other options include tattooing or plastic surgery. Reconstruction of the nipples is most often performed 2-3 months after mammoplasty, when the swelling of the breast subsides.
Breast implant after mastectomy
Breast reconstruction after a mastectomy is a restorative procedure that is performed after both complete and partial removal of the breast along with a malignant tumor. Almost all patients who have undergone a mastectomy resort to the most effective method of breast reconstruction - reconstructive plastic surgery, in order to return to a full life and feel feminine and attractive again.
The breast implant after mastectomy is inserted in one step (“single-stage reconstruction”). Most often, the implant is made of silicone (or rather, silicone gel and saline, taken in equal proportions). The implant is inserted through a small incision under the pectoralis major muscle.
It should be noted that after the implant is inserted under the skin, capsular fibrous tissue can form around it. This is a natural process that is associated with normal wound healing. In about 15-20% of cases, such a "capsule" can cause discomfort and provoke deformation of the mammary gland. In order to prevent such a process, the patient is recommended to perform physical exercises and a special restorative massage is prescribed. Radiation therapy increases the risk of formation of a scar capsule by 40-50%. Sometimes the implants can move, in which case a special massage is necessary. It should also be noted that most implants show little leakage over time (approximately 10 years). Such a process does not cause harm and does not cause dangerous consequences.
The advantages of the introduction of a silicone implant are the efficiency of the surgical technology and the low trauma of such an operation. Among the shortcomings, one can note the high cost of the procedure due to the rather high cost of endoprostheses.
Breast cancer recurrence after mastectomy
Reconstruction of the mammary glands after a mastectomy is carried out by introducing a prosthesis or an expander, depending on the specific situation. This operation can be performed in the process of mastectomy, or delayed for several weeks, until the wounds heal and the body recovers.
The recurrence of breast cancer after a mastectomy implies the re-development of oncology after a certain time after surgical treatment and chemotherapy. Unfortunately, this process occurs in most cases, especially if the cancer was diagnosed in the last stages. Most often, the tumor develops at the primary site, but a new tumor may appear in another breast or another area of the breast. The term "relapse" itself means the "return" of the disease. If the tumor is diagnosed in another place (internal organs, skeletal system, lymph nodes), this means that the cancer has “let go” of metastases.
Of course, the recurrence of cancer greatly frightens a woman and raises many questions regarding the correctness of the treatment technique and the operation performed. Most often, this problem occurs due to the fact that malignant cells cannot be completely identified and destroyed, and they enter the surrounding tissues with the blood or lymph flow.
If we talk about the time frame, then usually a relapse occurs in the period from 2 to 5 years after the course of therapy. If the development of such a process is suspected, an in-depth examination of the patient's body (MRI, PET), as well as a histological examination or biopsy, is carried out.
Among the prognostic indicators that allow predicting cancer recurrence, one can single out the aggressive course of the primary disease, the large size of the malignant neoplasm, and the diagnosis of the late stage of the primary disease. Neoplasms containing certain oncogenes, as well as the presence of malignant cells with a high atomic index, often lead to relapse. After surgical treatment of the patient, the oncologist must assess the situation for the possibility of recurrence in the future.
Palpation of the mammary glands is one of the main methods for detecting cancer. During the development of a relapse, the following symptoms may be observed:
- any changes in the nipple (shape, color, atypical discharge);
- itching and burning of the chest;
- changes in the structure and size of the breast;
- redness or any discoloration of the skin of the breast, a change in temperature.
In case of recurrence, local treatment is prescribed, including radiation therapy and surgery, as well as systemic treatment, which involves hormonal and chemotherapy. If in the first 5 years after treatment a relapse did not occur, then most likely there will be no recurrence of oncology.
Mastectomy or breast removal, which is used in the presence of cancerous tumors, leaves an indelible mark not only in the soul of a woman, but also on her body. After all, the absence of even one breast makes a normal life unbearable: you have to give up your favorite summer things, swimwear, and, therefore, a beach holiday. There may be difficulties in relationships with men and a serious decline in self-esteem.
But, fortunately, plastic surgeons offer a way out - breast restoration, which is performed in many clinics. Breast reconstruction surgery is not tied to a mastectomy, so it can be postponed indefinitely: the effect of the restoration will be the same after a month and after a year. Breast restoration can be done in one or several stages. However, surgeons recommend a one-stage operation, during which both the breast itself and the areola with the nipple will be restored.
Ways to restore the breast
Breast reconstruction can be done in several ways:The large amount of tissue taken allows you to model the breast as close as possible to the natural appearance, which will affect weight fluctuations like a real one. When restoring the mammary gland using a silicone implant, either only the prosthesis itself can be used, or implant combined with tissue expander.
Benefits of restoring with implants:
With this method, the risk of complications becomes much lower than when using only the implant. The chest looks much more natural. But there were some drawbacks:
Contraindications for all methods of breast restoration are the same:
Nipple and areola reconstruction
This is the final stage of breast reconstruction surgery, which is very important so that the new breast is no different from healthy and does not create physical discomfort. There are many methods for restoring the areola and nipple:Since such nipples tend to flatten out, the operation for reconstruction of the nipple will most likely have to be repeated again. The first operation can be performed approximately 3 months after the main breast augmentation, when the stitches have more or less healed and the swelling has subsided. Restoring the areola is easier than nipple, for this use:
Rehabilitation and terms after surgery
For some period after the operation, you will have to adhere to a certain routine and rules, under which healing will go faster.- Discharge after breast reconstruction occurs on the 3rd or 6th day after the operation itself, however, doctors recommend bed rest for the next few weeks.
- Any physical activity is prohibited for 3-4 weeks, you can not lift heavy objects above the chest.
- Within a month it is necessary to visit a doctor once a week, the stitches will be removed after 7-11 days. The final result of the operation can be seen in 2-3 months.
Photos before and after breast reconstruction surgery
Prices for breast reconstruction after mastectomy
It depends on the city in which the operation will be performed, on the clinic and plastic surgeon. Also important is the way in which the operation is performed, with the help of what materials, and how many stages will be needed for recovery. Therefore, the price in each case will be calculated individually, but judging by the data located on the website of the clinics, the price tag starts from 180 000 rubles.More and more people are suffering from cancer today. In women, the leading position is occupied by breast cancer. The most effective method of combating the disease is a mastectomy - an operation during which the complete or partial removal of the affected gland occurs. This procedure, although it saves the patient's life, often leads to psychological trauma and depression. A chance to avoid such consequences is breast reconstruction after mastectomy. In most cases, specialists use special prostheses during the procedure, but a number of techniques allow you to cope with the problem without them.
Indications and contraindications
The indication for breast reconstruction is its loss, which occurred in the course of the fight against malignant formation.
If the removal of the gland occurs for medical reasons and is done without fail, then the operation to restore it has a number of contraindications:
- progression of cancer;
- any violations of the immunological status of the patient's body, immunodeficiency states (including HIV);
- temporarily - monthly;
- infectious diseases;
- diseases associated with disruption of the internal organs;
- any chronic liver disease (including hepatitis C);
- blood clotting disorders;
- obesity;
- period after the end of lactation is less than a year;
- age up to 18 years;
- diabetes;
- unsatisfactory condition of the patient;
- the doubt of the woman herself in the expediency of the procedure.
The need for breast reconstruction
The need for breast reconstruction surgery after a mastectomy is due to several reasons:
- The psychological state of a woman.
- The resulting imbalance in the load on the thoracic spine (the load is greater on the side where the gland is stored).
- Secondary changes in the osteoarticular system due to an imbalance in the load on the spine:
- violation of posture;
- drooping shoulders;
- curvature of the spine. It can cause problems in the functioning of the chest organs, namely the lungs and heart.
Preparing for the operation
Preparation for breast reconstruction surgery includes several stages:
- surgeon consultation;
- carrying out a number of instrumental and laboratory studies;
- refusal of alcohol 2 weeks before the operation (so that there are no problems with anesthesia);
- stop smoking 2 months before the procedure (as it can slow down the healing process).
Reconstruction methods
Modern medicine offers several methods for breast reconstruction after mastectomy:
- Simple replacement of lost breast volume.
- Reconstruction using reduction mammoplasty methods:
- reconstruction through the use of implants;
- reconstruction using the Brava system;
- reconstruction through the use of musculocutaneous flaps.
Simple Volume Compensation
Today, doctors use a number of techniques to compensate for the volume of the breast. They are based on the transfer of a piece of breast tissue, its extension or rotation in order to fill the defect. At the same time, the shape of the breast is preserved, only its volume is reduced, therefore, a reduction of a healthy breast is usually required. This technique is effective only if no more than a quarter of the gland has been removed.
Application of implants
This method is used if the pectoralis major muscle is preserved, while the skin and subcutaneous tissue are of sufficient thickness and are characterized by mobility. The procedure itself takes place in two stages:
- Tissue stretching through the introduction of a tissue expander (it takes 5-6 months), this is the name of a special device designed to stretch the skin and form a cavity for the subsequent placement of the implant. The doctor sets the expander under the skin and, observing certain intervals, fills it with liquid. It is injected with a syringe. The entire procedure is performed on an outpatient basis.
- Replacing the expander with an implant. The type of implant depends on the filling used. It can be saline solution or silicone gel. At the same time, all prostheses have a shell made of solid silicone, their surface can be both smooth and textured. In shape, prostheses are round and anatomical (in the form of a drop). According to many plastic surgeons, silicone prostheses are preferable because they feel more natural and retain their shape better.
The use of this method has several advantages:
- the operation is less traumatic than the transplantation of the musculocutaneous flap;
- the required volume of skin appears twice as fast as when using a vacuum system.
However, this technique also has certain disadvantages:
- frequent visits to the doctor for an injection;
- unnatural appearance of the gland both by touch and visually;
- the existence of a risk of tissue necrosis over the expander (this can happen if the skin is stretched too quickly);
- prostheses are placed directly under the skin, which can cause ptosis;
- the presence of certain restrictions on the use of a number of implants associated with the density of the gel, which is necessary to achieve the result closest to natural.
Brava system
In addition to the expander, a special vacuum device, the Brava system, can be used to form excess skin. It is a special dome-shaped bowl worn on the chest area. A vacuum is created under it, due to which the skin is constantly in a taut state and stretches over time. The result is achieved after a long time, while wearing the system is required every day for at least 10-12 hours.
The main advantage of this technique is that the procedure is performed simultaneously with liposuction, which allows the surgeon to use not only implants, but also the patient's own adipose tissue during the reconstruction of the gland, in this case scars are not formed. The technique also has certain disadvantages:
- the need to wear the device every day for many months;
- it is difficult to achieve a strong stretching of the skin for an implant that is large;
- there is the possibility of the formation of a vascular network and stretch marks.
Breast reconstruction using this technique takes place in three stages:
- Preparatory. A woman wears the device for 10-12 hours for several months. This can be done both at night and during the day.
- Adipose tissue transplantation. With the help of liposuction, the doctor takes fat from places where there is an excess of it, and then injects it into the area of \u200b\u200bthe mammary gland.
- Final. To increase tissue survival, the Brava system is worn for another 3-4 weeks.
Reconstruction with musculocutaneous flaps
Breast reconstruction after a mastectomy can be carried out using musculocutaneous flaps (they are taken from the muscles of the back or rectus abdominis). This method is used in the following cases:
- skin and subcutaneous fat are thin;
- there are scars;
- large volume of preserved gland.
Application of the thoraco-dorsal flap
For surgery, the doctor may use a thoraco-dorsal flap (a flap taken from the latissimus dorsi muscle). Usually, during this procedure, the patient is placed with an implant, and a skin flap is needed to cover it. This technique gives the doctor more chances to model during the reconstruction of the gland, and the risk of complications is reduced. However, this type of reconstruction also has disadvantages:
- It is difficult to make the breasts look natural, since prostheses are installed during the operation.
- There is a noticeable scar on the back.
- Over time, the musculocutaneous flap atrophies, which reduces the cosmetic effect.
Application of the recto-abdominal flap
Restoring the volume of the lost mammary gland, the doctor can use a musculocutaneous flap from the rectus muscles of the lower abdomen. This technique has a number of advantages:
- It produces the greatest cosmetic effect.
- Often, prostheses are not used during the procedure, which ensures that there are no complications associated with them.
- The constitution of the gland is similar to that of a healthy breast. If the weight of the patient changes, the weight of the gland will change with him.
- Sufficient volume of tissues provides the specialist with many opportunities for modeling.
This procedure also has certain disadvantages:
- long-term rehabilitation;
- the possibility of necrosis of the musculocutaneous flap with its subsequent rejection;
- high invasiveness of the procedure;
- postoperative scars;
- anesthesia for a long time (4-5 hours).
Nipple areola restoration
Complete reconstruction of the breast is impossible without the restoration of the areola. To do this, experts can use different methods:
- reconstruction of the nipple from areola tissue taken from a healthy breast;
- skin grafting from the labia minora (in case of pigmentation);
- reconstruction of the nipple from the tissues that were used in the reconstruction of the breast, and pigmentation with the help of tattooing.
Healthy Breast Correction
When restoring a lost gland after a mastectomy, correction of a healthy breast may also be required, it is necessary to eliminate the asymmetry of the glands. In this case, the doctor can resort to different methods:
- mastopexy;
- mastopexy with gland reduction;
- mastopexy with breast augmentation (prostheses are used for this);
- the use of fillers;
- thread pull.
Complications
After breast reconstruction surgery, the following complications may occur:
- swelling;
- bleeding;
- infection;
- necrosis of the skin over the expander or skin flap;
- scars
- problems that cause prostheses (implant displacement or rotation, capsular contracture).
Recovery period
The recovery period after surgery depends on its type.
The most minimally invasive method is the Brava method. Recovery takes 2-3 weeks, and sick leave is needed only for 3 days. There are no restrictions, except for the refusal of thermal procedures.
If the doctor has chosen a technique using an expander, two operations are performed: the installation of an expander and its subsequent removal and replacement with an implant. After each of them, the patient must fulfill the following requirements:
- limit loads;
- refuse thermal procedures;
- avoid direct sunlight.
When dentures are fitted, women need to wear compression garments. Rehabilitation takes approximately 4 weeks.
The longest and most difficult is the rehabilitation period when restoring the breast with the help of a skin-muscle flap:
- stay in the hospital for about 2 weeks;
Oncological diseases of the breast are in the first place in women in the entire spectrum of cancers. Approximately 55,000 women are diagnosed with the disease every year, and the percentage is only increasing. Breast cancer leaves a mark on the social and personal life of patients, so the ability to recreate the breast is very important. Women who undergo surgery to remove their breasts during cancer treatment experience severe psychological trauma. For most patients, coming to terms with the loss is extremely difficult. In such cases, an option to solve the problem is breast reconstruction surgery, after which the breast restores its lost shape.
Most often, there is no break between mastectomy and breast reconstruction.
Most often, mastectomy and breast reconstruction surgery are performed at the same time.
The operation is performed by a plastic surgeon immediately after the oncologist surgeon has removed the mammary gland.
It is not always possible to simultaneously perform a mastectomy and restore the mammary gland. Sometimes it is required to wait a certain amount of time, it all depends on the state of health of the patient.
Breast Reconstruction Techniques
The choice of breast reconstruction technique depends on the woman's health, medical indications, breast size and shape, as well as on the recommendations of the surgeon and the desires of the patient herself.
At the moment, there are several methods for the reconstruction of the mammary glands. Each of them has its own characteristics, disadvantages and advantages. Which one is the best?
Let's look at three main ways:
- breast reconstruction with implants
- breast reconstruction with a recto-abdominal flap
- breast reconstruction with local tissues breast reconstruction with thoracodorsal flap
The choice of method depends on how much tissue was removed from the patient during the mastectomy and on the complexity of the previous operation.
Breast reconstruction using an implant
This method allows you to restore the lost volume of the mammary gland by installing a breast implant. It happens that there is not enough skin on the chest to restore, then you first need to install a tissue expander - a soft tissue stretcher, and then install the implant.
Disadvantages of breast reconstruction with implants:
- imperfect result from the operation in terms of aesthetics
- possible risk of complications (necrosis of the skin flap, formation of scar tissue) dense to the touch, unnatural breasts
- the implant is visible through the skin
Reconstruction of the breast with a recto-abdominal flap (TRAM flap)
TRAM flap (Transverse Rectus Abdominis Myocutaneous - transverse flap of the rectus abdominis muscle) is currently considered by surgeons to be the best method of breast reconstruction. Using this technique, a sufficient amount of tissue and skin can be obtained. The principle of operation is that during the operation, a flap is excised from the lower abdomen. It consists of fascia, skin, muscles and adipose tissue. This flap is placed under the skin into the chest area. To improve blood circulation, if necessary, blood vessels are sutured to the vessels of the flap.
Contraindications for the TRAM flap repair method:
- women who smoke should not have surgery
- not recommended for obese patients
Breast reconstruction with local tissue
In cases where, after a mastectomy, the patient does not have enough material for a complete reconstruction, restoration is carried out with adjacent tissues. This option is the restoration of the mammary gland with a flap taken from the lateral surface of the chest wall. In aesthetic terms, this method gives good results. Local flaps have a texture and skin color similar to that of the skin of the breast. The way the flap is moved is not very complicated, and the recovery period of patients proceeds without any special complications.
Disadvantages of the local tissue reconstruction method:
- adjacent flap has no axial circulation
- difficult to predict blood supply to the distal part of the flap
- partial development of skin necrosis of the local flap
Breast reconstruction with a thoracodorsal flap
When using this technique, an implant is also used, which is covered with a flap from the latissimus dorsi muscle. This method reduces the risk of possible complications and, when modeling the shape of the breast, provides ample opportunities for the plastic surgeon.
Disadvantages of thoracodorsal flap repair:
- scars remain on the back
- over time, the musculoskeletal flap atrophies and the aesthetic quality of the breast decreases
Preparing for the operation
It is necessary to undergo a thorough examination, pass a lot of tests (general blood test, urine test, biochemistry test, bilirubin, sugar, HIV, etc.), consult a mammologist, oncologist and conduct an ultrasound of the mammary glands. At the consultation, the doctor will most likely recommend to refrain from taking certain types of drugs (aspirin, hormonal drugs, vitamin E), to exclude alcohol and smoking.
Breast reconstruction surgery is performed under general anesthesia.
What precautions should be taken after breast reconstruction surgery?
- about two months after the operation, wear special underwear
- do not lift weights for a month
- give up physical activity
- undergo regular examinations (mammography, ultrasound), doctor's consultations
- exclude trips to saunas and baths for a month
Possible Complications After Breast Reconstruction
- suppuration may develop in the area of operation, blood and serous fluid may accumulate (may lead to a second operation)
- scar formation
- breast asymmetry
- necrosis of part of the flap
- formation of capsular contracture
FAQ
From the point of view of the aesthetic result, is a one-stage reconstruction (if possible) better than a delayed one?
According to the head of the surgical department of reconstructive and vascular surgery of the N. N. Blokhin Russian Cancer Research Center Vladimir Sobolevsky, a one-stage operation is certainly better.
Sobolevsky: “Firstly, due to the fact that during a mastectomy it is not always necessary to remove the entire skin of the mammary gland (this is not possible in all cases and depends on the stage of the disease and the prospects for treatment). Secondly, in Russia and around the world there is a trend towards individualization of treatment. In the situation of locally advanced cancer involving the skin, preoperative treatment is required and after it a radical mastectomy with removal of all skin, all gland tissue and axillary lymph nodes is assumed to be mandatory radiation therapy after surgery. In such cases, it is better to do the reconstruction a little later, because if it is done immediately, during the mastectomy, the aesthetic result will worsen on the background of radiation therapy.”
Does radiotherapy impair healing after reconstruction?
According to Dr. Sobolevsky, radiation therapy worsens the aesthetic result, but not due to the difficulties of healing, since it is carried out after it, but due to fibrosis and deformation of all tissues that fall into the field of radiation therapy.
Are there situations in which reconstruction using only one's own tissues, using the TRAM method, is possible? Or is there always a choice?
Sobolevsky is convinced that there is always a choice.
The doctor notes: “There are two aspects in the treatment of patients: medical and aesthetic. While doctors practically do not discuss the medical part with patients, the aesthetic aspect is always discussed with patients. The choice of reconstruction method is always a very difficult problem. There is no universal method that would suit all patients. The choice also depends on the treatment plans: on whether it is possible to save the skin during the removal of the gland and in what areas, on the volume of the gland, on the availability of one’s own tissues for reconstruction, on the constitution and somatic condition of the pain.”
Prices for the operation
The cost of breast reconstruction surgery varies from 100,000 to 190,000 rubles
Prices for breast reconstruction surgery vary depending on the technique used.
The average price for breast restoration is from 100-190 thousand rubles, depending on the volume of the proposed intervention.
- In the Clinic of Plastic Surgery and Reconstructive Medicine of Dr. Shah, the price for reconstruction will start from about 100,000 rubles (in each individual case, the exact price must be clarified at the clinic).
- The cost of breast reconstruction in the clinic "Plastic Surgery" is from 100,000 rubles.
- In "GarantClinic" reconstructive mammoplasty costs 190,000 rubles
- According to Dr. Grishkyan, the price for breast reconstruction depends on the method and complexity of the operation (more than 100,000 thousand), the exact price should be clarified at the clinic.
Special offers
Dr. Shcherbakov K.G. will hold free reconstructive mammoplasty after mastectomy!
All participants who survived mastectomy can take part in the action. Requirements:
- no recurrence of the disease (relapse)
- six months have passed since the last chemotherapy
The finalists will be announced in early February. Get involved and take the chance to change your appearance for the better!
Considering the methods of performing breast reconstruction surgery after a mastectomy, one cannot confidently lean towards a certain method of breast reconstruction. Aesthetically high-quality results can be obtained using both implants and the patient's own tissues. Each method has its drawbacks and positive aspects. The surgeon will choose the method that, in his opinion, will best suit a particular woman.
The main thing to remember is that before any breast reconstruction, a mastectomy was preceded - the removal of the mammary gland, and the result of further reconstruction largely depends on the correctness of this operation.
Rbreast reconstruction after mastectomy performed using implants, own tissues, or a combination of both methods. Which method is better? Will the reconstructed breast look natural? When is it better to perform reconstruction, simultaneously with a mastectomy or delayed? These and other questions we asked the professor, doctor of medical sciences Vladimir Sobolevsky.
- Is a mastectomy mandatory when breast cancer is detected?
In the initial stage of the disease, a mastectomy is not always necessary. If the volume of the gland is large, the tumor is small, located far from the central sections, it is possible to perform a radical resection, that is, to save most of the mammary gland. However, with stage 1 or 2 disease and the need for a mastectomy, in most cases, a subcutaneous or skin-sparing mastectomy can be done. The difference between them is as follows: in a subcutaneous mastectomy, the entire breast skin and SAH are left, while in a skin-sparing mastectomy, the nipple, areola, and breast tissue are removed. If it is possible to save the skin pocket of the breast, then the aesthetic result will be better when performing a one-stage reconstruction. The suture will pass only under the breast or only around the areola, and it does not matter what this pocket will be filled with, with its own tissues or an implant, or a combination of an implant and the latissimus dorsi muscle - aesthetically it is better than a delayed reconstruction
- From the point of view of the aesthetic result, is a one-stage reconstruction (if possible) better than a delayed one?
Certainly better. First of all, due to the fact that during a mastectomy it is not always necessary to remove all the skin of the breast. True, this is not possible in all cases and depends on the stage of the disease and the prospects for treatment. Now, both in our country and all over the world, there is a tendency towards individualization of treatment - not only for breast cancer, but also for other oncopathologies. In the situation of locally advanced cancer involving the skin, preoperative treatment is required and after it a radical mastectomy with removal of all skin, all gland tissue and axillary lymph nodes is assumed to be mandatory radiation therapy after surgery. In such cases, it is better to do the reconstruction delayed, since if it is done immediately, during a mastectomy, the aesthetic result will worsen on the background of radiation therapy.
Does radiotherapy impair the healing process after reconstruction?
Radiation therapy worsens the aesthetic result, but not due to the deterioration of healing, since it is carried out after it, but due to fibrosis and deformation of all tissues that fall into the field of radiation therapy. If reconstruction was made with own tissues, these tissues are sclerosed. If the breast is reconstructed with an implant, capsular contracture very often occurs.
- Radiation or chemotherapy necessarily accompany a mastectomy?
Not necessary. The method of treatment depends on the stage of the disease, the involvement of lymph nodes in the process and the type of tumor immunohistochemistry. If the tumor is highly receptor-dependent, then, as a rule, only hormone therapy is prescribed after surgery.
Breast cancer is a group of diseases that includes more than five completely different diseases. There is a set of diagnostic procedures that allow you to determine cancer, its immunochemical subtype, the level of estrogen and progesterone receptors, the degree of cell atypia, Ki-67, Her-2neu, the prevalence of the process, whether the disease is localized in the gland or is there an interest in regional lymphatic collectors, are there any distant manifestations of the disease. Depending on the immunohistochemistry, tumors are treated differently, with different prospects and prognosis.
After the localization of the tumor is determined, a decision is made: to start with surgery or chemotherapy (if the process is common). If the process is localized, we start with the operation and after it, after obtaining the histology of the removed tissues, we determine whether it is necessary to carry out chemotherapy, hormone therapy, or both.
Sometimes the need for radiation therapy is clarified after surgery, after obtaining the final histology. The standard worldwide is to conduct radiation therapy in the postoperative period, if we found more than 3 affected lymph nodes during histological examination. Radiation therapy is performed after healing and removal of sutures. If both chemotherapy and radiation are required, then chemotherapy is given first, and at least 2-3 months must pass before radiation.
- Tell us about lumpectomy - an operation in which only part of the mammary gland with a tumor is removed.
Lumpectomy is rarely done here in Russia. A lumpectomy is an operation in which only the tumor in the breast is removed. This requires mandatory interoperative radiotherapy, and in some cases external beam radiation therapy is still performed. Such operations are indicated for a small group of patients with hormone-dependent tumors up to 2 cm in size. As a rule, these are elderly women. Units for intraoperative radiotherapy are very expensive (40-60 million rubles) and they are installed only in centers that do not have external beam radiotherapy. We do not have facilities for intraoperative radiotherapy. But aesthetically, a small radical resection would be the same as a lumpectomy.
Choosing treatment tactics, we focus not only on Western standards, but on the standards approved by the Ministry of Health. For example, in the initial stages of the disease, if, according to ultrasound, the lymph nodes are not changed, in the West they only do a biopsy of the sentinel lymph node: they take one lymph node under the arm, do an urgent study, and if there are no metastases, they do not remove it. The axillary lymph nodes are a regional area of breast cancer metastasis and very often cancer metastases are detected in them. Until recently, their removal was the standard in the West. Now they are not removed for all stages and forms of cancer.
In our country, unfortunately, according to the standards of the Ministry of Health, in case of infiltrative breast cancer, all lymph nodes under the arm must be removed. This is not always necessary, it is not entirely justified, but it takes time, effort and energy to review and change the standards of the Ministry of Health in the right direction.
- Can the patient refuse to remove the lymph nodes?
No. She may refuse treatment and go abroad for treatment. Our research institute is a scientific center, it belongs not to the Ministry of Health, but to the Academy of Sciences, therefore, in the framework of scientific protocols, in some cases we may not perform such an extensive lymph node dissection.
- Are there situations in which reconstruction is possible only with own tissues, using the TRAM method? Or is there always a choice?
There is always a choice. There are two aspects to the treatment of our patients: medical and aesthetic. If we practically do not discuss the medical part with patients, depending on the stage and type of tumor, they are supposed to receive one or another treatment, then we always discuss the aesthetic aspect with the patient.
The choice of reconstruction method is always a very difficult problem. There is no universal method that would suit all patients. The choice also depends on the treatment plans: on whether it is possible to save the skin during the removal of the gland and in what areas, on the volume of the gland, on the availability of own tissues for reconstruction, on the constitution and somatic condition of the patient.
TRAM is not the only way to reconstruct with your own tissues. There are a lot of areas where you can take your own fabrics, and TRAM is the oldest and easiest method. A simple transposed TRAM flap includes the rectus abdominis muscles and a transverse skin-fat flap. The flap is moved on the muscles to the site of reconstruction. Modern techniques make it possible to use only a skin-fat flap on a vascular pedicle (rather thin arteries and veins that supply blood to this flap). You can use other flaps: gluteal, from the hip, from the back. Now there are microsurgical techniques that are less traumatic than traditional ones. We do not use the abdominal muscles, we take only a fat flap. It is possible to transfer tissue without muscle on microvascular anastomoses from the abdomen, from the inner surface of the thigh, from the upper or lower gluteal region . In the area with excess tissue, we can take them with a minimal cosmetic defect and fill the pocket after removing the breast tissue.
The latissimus dorsi muscle is quite often used in reconstructive operations on the mammary gland. Most often it is used to cover the lower pole of the implant (especially if it is large), while the upper pole of the implant is placed under the pectoralis major muscle. In some cases, the muscle is taken with a small skin area, which can be used to reconstruct the SAH. When reconstructing a gland of a small volume, the skin pocket can be filled with one latissimus dorsi muscle. To do this, you need a small incision (5-6 cm) on the back along the linen.
- Which reconstruction method will make the breast more or less sensitive?
It does not depend on the type of reconstruction, but on whether the nipple and innervation are preserved. Sensitivity is violated almost always. Our task, first of all, is to restore the shape and volume, and, if possible, the consistency of the mammary gland. The choice of method depends on many factors: excess or lack of tissues, where and how much skin can be saved, on the condition of the second mammary gland - after all, symmetry is needed, and in half the cases it is necessary to perform a corrective operation on the other side.
How is symmetry achieved during reconstruction? Is it possible to make an individual implant more similar to the second breast shape?
If we are talking about a woman 20-30 years old with a good volume and shape of the mammary gland, then when performing reconstruction with an implant or expander, we try to create a mammary gland of a spherical shape, good filling. If a woman is operated on with a pronounced ptosis, an empty second gland, stretched skin, a projection of the nipple below the submammary fold, there is no point in trying to create a second similarly ptotic gland. Both in the West and in our country, corrective surgery for the second gland - mastopexy or augmentation - is a common practice.
- How is the incision made for immediate reconstruction and what shape will the suture be?
The incision is made not during reconstruction, but during mastectomy, and the shape of the incision depends on its type. The standard mastectomy incision is a horizontal scar from the sternum to the edge of the armpit.
In the West, mastectomy is done by a general surgeon and reconstruction by a reconstructive surgeon. These two specialists are preparing for the operation together and doing each of their steps. Everything is done by one person. This has its pros and cons. When performing a mastectomy, I can already position the incision in a way that suits me so that after the reconstruction it will be in an aesthetically insignificant area.
- Tell us, please, about the restoration with a tissue expander.
The use of a tissue expander involves a two-stage reconstruction and is performed when both breast tissue and a large amount of breast skin need to be removed. For example, in a locally advanced process involving the skin of the breast, it is necessary to treat it before surgery, then do a radical mastectomy without saving the skin, and then radiation therapy may be needed. Having performed the operation, we can immediately place a tissue expander, conduct radiation therapy, and after its completion, through the built-in or external port in the expander, stretch the skin of the anterior chest wall (filling the expander with saline) to create a supply of skin for the future mammary gland.
It usually takes at least 3 months from the first stage (mastectomy and insertion of the expander) to the second (implantation) for a capsule to form around the expander. The capsule is a valuable plastic material that we work with when replacing the expander with an implant, forming a submammary fold. If the expander is replaced with your own fabrics, it may take less time. In general, the process takes no more than 6 months.
- Does the expander affect the future shape of the breast?
Affects. There are different types of expanders: anatomical expanders take a teardrop shape when inflated, round expanders evenly stretch the skin. The choice is made depending on where you need to stretch the skin - in the lower pole, middle, upper. Expanders differ in width and height of the base, in projection, and are selected individually for each patient.
- Tell us about the filling of expanders and implants. Which manufacturers' products are used in breast reconstruction?
All expanders are filled with saline. The implants are filled with either silicone gel or saline. Mentor and McGhan also produce endoprosthesis expanders, expandable implants: this product combines both an implant and an expander. There is a cavity inside such a prosthesis and through an external port (a tube with a portico), the surgeon can inject a solution that will increase its volume - not much, up to about 150 cm 3. As long as the port is not removed, the volume can be changed. After reaching the desired solution size, the portico is pulled out and the valve is closed.
The choice of implants is great, there are a lot of manufacturers, there are Korean, English, French brands. I have not heard about Russian-made products.
- What implants do you use in your practice?
Different. We have a state medical institution and operations are performed according to quotas issued by the Ministry of Health. Patients do not pay for either implants or expanders, their cost is covered by a quota. Our institute has a government contract with Mentor, and I am satisfied with their products. Basically, the products of manufacturers are oriented to the market of aesthetic surgeons who perform breast augmentation, and they need a wide range of conventional implants, and not expanders and endoprosthesis expanders. The products we need are available from Mentor and 2-3 other companies.
- How predictable is the shape of the breast and how does the chosen reconstruction method affect the shape?
It largely depends on the professionalism and experience of the surgeon. The second factor that can affect the shape is radiation therapy, during which, as a rule, the created gland is deformed. Also, the shape depends on the method of reconstruction. A priori, reconstruction with own tissues is better than with an implant. But according to statistics around the world, reconstruction with the help of implants is more often chosen, since it is technically simpler, the recovery period after the operation is shorter, there is no additional scar: implants have a number of advantages. However, iron, restored by its own tissues, looks more natural. Its volume and shape change naturally with age, as does the shape of a second, healthy breast. The consistency of such breasts is more natural. In addition, over time, the result only gets better, while the breast restored by the implant will sooner or later need to be operated on again. The consistency of the breast with an implant is denser and it does not change over time, capsular contracture increases.
- Is lipofilling used in Russia for breast reconstruction?
Yes. But not as an independent method of reconstruction. I'm pretty sure that no one except Roger Kouri uses it as a mono-method for reconstruction. But almost everyone uses lipofilling as a method of correction after reconstruction in those places where there was not enough adipose tissue. The procedure is performed on an outpatient basis under local anesthesia, it is safe and gives a good result.
- Tell us about the methods of reconstruction of the SAC.
There are different ways, the choice depends on how the gland itself is reconstructed. If with own tissues, then usually the nipple is made from the same flap according to certain patterns, and the areola, as a rule, is tattooed later. The naturalness of the tattooed areola depends on the tattoo artist. Of course, if the areola is blurry, has fuzzy contours of pigmentation, it is more difficult to recreate it, and in this case it is recommended to make a tattoo and the second areola.
Just as there is no one ideal method for breast reconstruction, there is no one-size-fits-all method for nipple reconstruction. In each case, this is done in its own way. During reconstruction with own tissues, for example, a specially shaped flap is cut out and stitched in a certain way. With a two-stage reconstruction using an expander, the skin is stretched and it is not possible to cut out exactly such a flap, then a piece of synthetic material is placed inside the future nipple instead of its tissues.
- What are the features of mastectomy with SAH preservation and further reconstruction? Is the result in this case the most natural?
The result depends on the shape of the gland and the severity of ptosis. If the ptosis is not pronounced, the projection of the nipple is above the submammary fold, the skin is not stretched, the tumor is far from the nipple and areola, then at the initial stage of the disease, we can make an incision in the submammary fold, remove all the glandular tissue under the skin and replace it with an implant or own tissues. If the ptosis is severe, the preservation of the nipple and areola is likely to lead to necrosis of the nipple, and there is no aesthetic sense in this. It is not difficult to get a new nipple and areola tattoo, it will look better.
But in Russia, situations are rare when a mastectomy with preservation of the SAH is possible - we have few patients with the initial stage of the disease. There is no medical examination, people are very irregularly examined. It is possible to detect oncological diseases at the initial stage only with regular examinations of healthy people. The tumor never hurts, it develops from its own tissues. The slightest mastitis after childbirth gives terrible pain and the patient immediately runs to the doctor, and the tumor of a rather large size does not bother, does not manifest itself and the woman does not get to the doctor. We have very little literature for patients, people are afraid to go for an examination: “What if they find cancer in me? I'd rather not go." The task of the state and the media is to convey to people that today breast cancer in the initial stages in 95% can be cured. Previously, after treatment, patients lived for 2-3 years, so the issue of reconstruction was practically not raised. Now, after recovery, patients live a full life, for a long time, the reconstruction is relevant and gives an excellent aesthetic result.
Examples of breast reconstruction after mastectomy
Patient 1 (40 years old)
Delayed reconstruction of the right mammary gland with the Becker expander endoprosthesis 2 years after RME. Photos before and 1 year after reconstruction.
Patient 2 (49 years old)
Bilateral delayed reconstruction of the mammary glands with thoracodorsal flaps and Spectra implants was performed.
Patient 3 (40 years old)
Skin-sparing radical mastectomy with simultaneous reconstruction with a relocated TRAM flap. Photos before and 3 years after reconstruction.
Patient 4 (34 years old)
A subcutaneous radical mastectomy was performed with preservation of the pectoral muscles with simultaneous reconstruction with the Becker expander endoprosthesis and a thoracodorsal flap.
Patient 5 (38 years old)
A delayed reconstruction of the left breast with an expander (stage 1) was performed, then the expander was replaced with an implant on the left and augmentation on the right.
Patient 6 (43 years old)
In 1995, subglandular breast augmentation was performed. In 2013, cancer of the left breast was diagnosed. Left radical mastectomy was performed with partial skin preservation with simultaneous reconstruction of the left breast with an implant and a thoracodorsal flap. Repeated subpectoral augmentation on the right. Then 4 courses of chemotherapy were carried out and endocrine therapy was prescribed.
Photos before treatment and 3 months after.
Patient 7 (40 years old)
A delayed reconstruction of the right mammary gland was performed, prophylactic mastectomy on the left with one-stage reconstruction. Stage 1 - installation of the expander on the left. Stage 2 - prophylactic mastectomy on the left and reconstruction of both mammary glands with a split TRAM flap. Then the formation of the nipple-areolar complex on the right.
In the photo: before the start of treatment, after the second stage, 3 months later, a year after the reconstruction.
All operations, the results of which are shown in the photo, were performed by Sobolevsky V.A.
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