Breast reconstruction
One woman in nine experiences breast cancer over her lifetime. The number of survivors is expected to rise in the next decade. Although breast conserving surgery and radiotherapy are one of the mainstay of treatment, total mastectomy still is a frequently offered solution in a therapeutic and prophylactic manner.
The mastectomy defect can be devastating both psychologically and physically on many women. Extensive literature clearly supports the oncologic safety and advantages (improvement in body image, quality of life and mental health) of breast reconstruction.
It can be undergone with alloplastic (implants) or autologous (flap = vascularized piece of multiple tissues such as skin, fat and muscle) techniques. No one procedure outshines all the others. To each its indication. The overall indication is a result from a discussion between the patient and surgeon.
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Single-stage breast implant
Two-stage breast tissue expander then delayed implant
Two-stage breast tissue expander then delayed autologous flap
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Free Deep Inferior Epigastric Artery Perforator (DIEP) flap
Free Profunda Artery Perforator (PAP) flap
Pedicled Latissimus Dorsi (LD) flap
Radiotherapy is the cancer cells’ enemy as well as our own. Over the past 10 years, guidelines change has led to increased use of radiotherapy.
It has been shown to cause worse aesthetic outcomes and volume loss with autologous techniques, and the risk of capsular contracture and wound-related complications with implant-based techniques.
In this setting, autologous flaps appeared to have superior outcomes as well as lower reoperation rates than with implant reconstruction.
The decision is independent of the plastic surgeon. Survival comes first.
Depending on the case, breast reconstruction can be performed immediately after the mastectomy or on a delayed basis.
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Safe even in advanced breast cancers (no increase in recurrence)
Conserves pliable and soft native breast skin (which is the best) and acts before scarring.
Immediate return of body image without passing by an intermediate “no-breast” stage
Faster return to activities of daily life
Fewer operations and general anesthesia
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Generally used in patients in whom post-operative radiotherapy is certain or very likely
Gives patients more time to think about options and focus on cancer treatment
Skin is less pliable and scarred therefore the final result is less natural
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When it is uncertain if the patient will undergo post-operative radiotherapy, this will conserve the breast envelope and impede scarring of the skin on the muscle.
An breast tissue expander is put inside the breast pocket and left marginally inflated
If radiotherapy is indicated, the expander is left deflated and the radiotherapy can proceed
If no radiotherapy is indicated, the expander is inflated and breast reconstruction is undertaken.