It is the process of rebuilding breast tissue that has been removed due to cancer or other reasons. With advancing techniques, it is possible to perform reconstructions that closely resemble the other breast. This surgery can be performed in the same session following the removal of breast tissue, as well as later.
Breast reconstruction can be grouped under two headings;
Breast reconstruction with a tissue expander and implant
Breast reconstruction with transfer of the patient's own tissue.
The method using a tissue expander and implant is the most commonly used. In the first session, a pocket for the breast implant is created with a tissue expander. In the second session, the breast implant is placed and symmetry with the other breast is achieved. After the tissue expander is placed, it is inflated with saline (SF) for approximately three months. In reconstructions with tissue transfer, tissue is taken from another area of the body (abdomen, back, etc.) along with its blood supply and transferred to the defect area, the mastectomy site. No breast implant is used. After surgery, asymmetries with the other breast may occur; however, these can be corrected with revisions.
Breast Reconstruction
The breasts are very important organs, particularly for women, consisting of the skin envelope that includes the nipple and areola, the fatty tissue within, the mammary gland tissue, and the underlying muscle tissue. In addition to their roles in breastfeeding and nursing after childbirth, they are an important area of female sexuality and appearance. Symmetrical, healthy breasts of proper shape and size play a major role in ensuring a self-confident and happy life for women. In women who have no breast or only one breast, whether congenital, after trauma, or most commonly after mastectomy surgery (removal of breast tissue), this deficiency may manifest psychologically and cause difficulties in clothing choices and sexual life. Patients may develop ‘post-mastectomy depression’. With increasing surgical techniques and success rates, the reconstruction of missing breast tissue in women, i.e., breast reconstruction, is generating growing demand.
Who can undergo breast reconstruction?
Any woman who has no breast or only one breast and whose general health allows her to tolerate surgery can undergo breast reconstruction. In the vast majority of patients who have undergone mastectomy, there is no medical obstacle to breast reconstruction. Different methods may be more suitable for different patients and may yield more successful results.
The effect of breast reconstruction on breast cancer treatment
Breast reconstruction has no known risk regarding breast cancer recurrence. Furthermore, radiotherapy (radiation therapy) or chemotherapy (drug therapy) given as part of treatment is not affected by breast reconstruction. Methods used in breast cancer follow-up can also be applied after breast reconstruction. However, in patients reconstructed with a breast implant (silicone), MRI examination is more suitable than mammography for follow-up.
Breast reconstruction after mastectomy
Early reconstruction: Breast reconstruction can be performed after mastectomy, as well as at the same time as the mastectomy. With the increase in early diagnosis of breast cancer, ‘immediate reconstruction’ practices have begun to increase. Reconstruction performed immediately during the same surgery as the mastectomy is more successful in terms of the patient's psychosocial adjustment after surgery and eliminates the need for a separate surgical procedure for reconstruction. Immediate reconstruction may be easier for the surgeon, and aesthetic results are better. Its disadvantage is that combined breast cancer surgery and reconstruction surgery take longer and the recovery process is longer.
Delayed reconstruction: Breast reconstruction may be postponed to a later time after mastectomy on the recommendation of the general surgeon and oncologist, or due to reasons such as the patient not requesting it, being severely overweight, smoking, having high blood pressure, or being unable to tolerate a long operation. In such cases, some patients may focus on treating the underlying breast disease. It may be more appropriate to determine the definitive stage of the disease together with the surgery performed for breast cancer and to plan radiotherapy if necessary. In this case, reconstruction is postponed to avoid the side effects of radiation. In our country, breast reconstruction is generally performed this way, ‘late’, at a later date.
Breast reconstruction options
Breast reconstruction is performed using 2 main methods:
Breast implants
Autologous reconstruction (with the patient's own tissue)
Silicone breast implants: They may be preferred because the surgery is easier and they are a relatively safe reconstruction option that does not require a long surgical time. They are preferred in patients who cannot tolerate long surgery or do not want another part of their body operated on. The disadvantages of this method can be listed as the risk of poor aesthetic outcome, infection risk, skin necrosis risk, capsule formation risk, displacement, and asymmetry. This risk is higher in patients who have also undergone radiotherapy.
The patient does not have suitable autologous body tissue for breast reconstruction,
The breast tissue area is not poorly scarred or infected,
A prophylactic (preventive) mastectomy has been performed,
Bilateral breast reconstruction is being performed,
The patient has permitted other breast surgery to achieve symmetry,
The patient has not received radiotherapy to the breast or chest wall; such a patient is an ideal candidate for breast reconstruction with a silicone breast implant.
Tissue expanders: In some patients, if there is insufficient subcutaneous pocket for a breast implant, a tissue expander may be used. This is a staged method. The subcutaneous tissue expander placed in the breast area is inflated with saline 10-15 days after surgery and at 3-5 day intervals; once an adequate pocket is achieved, this silicone-based expander is removed and a silicone breast implant of the planned size is placed. Disadvantages of this reconstruction method include that it is a two-stage surgery, that the inflation procedure performed at various intervals, which can take a total of 2-3 months, may sometimes cause mild pain, and that capsule formation, infection risk, skin loss, and asymmetry may be seen. Each surgical stage of the method takes about 1 hour.
Dual-lumen adjustable implants: When an implant is planned for breast reconstruction and there is insufficient pocket, and avoiding a double surgery is desired, a Becker implant may be used. This implant is a permanent tissue expander. This dual-lumen implant, which has an inner cavity that can be inflated with saline and silicone gel in its outer lumen, is placed permanently. After surgery, the inner part is inflated with saline to the desired size and left in place. Adjustments can be made as desired, and asymmetry can be prevented more easily.
Autologous breast reconstruction: Breast reconstruction performed using skin, fat, and muscle tissue taken from another area of the patient's own body is called autologous reconstruction. The most important difference distinguishing autologous breast reconstruction from implant-based reconstruction is that, because it uses the patient's own tissue, it gives a natural appearance and does not carry risks such as rejection of the prosthesis, infection, capsule formation, skin loss, or the need for replacement. There are various options for autologous reconstruction. The most important are the TRAM flap and DIEP flap from the abdomen, the latissimus dorsi flap from the back, the TUG flap from the thigh, gluteal flaps from the buttock, and Ruben's fat pad flap from the lateral waist area. Using tissue obtained from the abdominal area is the most commonly used autologous breast reconstruction option.
TRAM flap: The TRAM (transverse rectus abdominis myocutaneous) flap is a method in which skin, subcutaneous fat, and muscle tissue in the lower abdomen, below the navel, are lifted as a block from the abdominal wall and used for breast reconstruction. After surgery, a horizontal scar remains in the lower abdomen, similar to but longer than a cesarean section scar.
Patients who want autologous breast reconstruction,
Patients who are not good candidates for implant reconstruction,
Those with sufficient tissue in the lower abdomen,
Those who have not previously had abdominal surgery (such as abdominoplasty…),
Those in whom breast reconstruction with an implant has previously failed,
Those requesting reconstruction at the time of mastectomy or later,
Those with a body mass index not exceeding 30 and without a very large excess of tissue in the lower abdomen,
Those whose general condition allows them to tolerate prolonged anesthesia,
Non-smokers,
Women without diabetes are ideal candidates for breast reconstruction using abdominal tissue with this method.
This flap, obtained from the superficial abdominal tissue, is used in breast reconstruction with various techniques:
Pedicled TRAM flap: The abdominal skin and underlying muscle tissue are not completely separated from the body surface; using the transverse rectus abdominis muscle as a stalk, a tunnel is created under the skin from the abdomen to the breast, and the tissue is rotated to the area where the breast is to be formed and shaped into a breast. The abdominal area from which the tissue was taken is closed with appropriate suturing techniques, as in an abdominoplasty, and the navel is recreated (repositioned). In some patients, removing excess abdominal tissue is also an aesthetic advantage. This extremely natural breast reconstruction option requires caution in obese, smoking, and diabetic patients. Wound healing problems, flap blood supply problems, flap loss, fat necrosis, and abdominal wall hernias are possible complications. To prevent hernia, a synthetic material called mesh is used during closure of the abdominal area to strengthen the area from which muscle tissue was taken.
Delay and supercharge method: To strengthen the single-vessel blood supply of a TRAM flap that has two vascular supplies, one of the vessels may sometimes be disconnected from the tissue through a brief surgery before the main operation. With this method, called delay, the TRAM flap to be rotated is intended to be healthier and more viable. Sometimes, when the TRAM flap tissue is rotated to the area where the breast will be formed, one of the tissue's supplying vessels is repaired by microsurgically connecting it to the vessels in the recipient area. In this method, called ‘supercharge’, viability is strengthened by providing the tissue with additional blood supply. Thus, the aim is for the tissue's blood circulation to be healthier.
Free TRAM flap: This involves completely separating the TRAM tissue in the abdomen from the abdominal wall along with its feeding vessels using microsurgical techniques, and creating the breast by reconnecting it microsurgically (anastomosis) to the vessels in the area where breast tissue is to be formed. Compared with the pedicled method, this method requires more advanced techniques; when performed correctly, however, there is less risk of tissue loss and fewer abdominal wall problems. If vessel blockage occurs, there is also a risk of losing the entire tissue.
DIEP flap: The main vessels supplying the abdominal tissue planned for breast formation are the deep inferior epigastric vessels. These vessels enter the muscle tissue and give off perforator branches that run perpendicularly toward the skin. In the DIEP flap technique, one of these vessels is identified using microsurgery, and the tissue is used to create the breast in the recipient area, again using microsurgical techniques, while causing the least possible damage to the abdominal wall muscle. The most important advantage of this method is that it causes the fewest problems in the abdominal area and minimizes hernia risk.
Other tissues used for breast reconstruction
The latissimus dorsi muscle in the back, alone or together with some skin tissue, can be used to form the breast. Although this method provides sufficient covering tissue in most women, it cannot provide the fullness and contour needed to create a breast appearance. In some patients it can be used to close the opening in the breast area during mastectomy, and sometimes, when used together with a silicone breast implant, it can be used to achieve adequate breast size and contour. A disadvantage of this method is that it leaves a scar on the back that is difficult to camouflage and may cause wound healing problems. When abdominal and back tissues cannot be used, ‘gluteal flaps’ from the buttock, ‘Ruben's fat tissue’ from the lateral waist, and the ‘transverse upper gracilis flap’ from the inner thigh may be used as free flaps with microsurgical techniques for breast reconstruction. Additionally, in some patients, tissues near the breast may also be used for partial breast reconstruction.
Healing process after breast reconstruction
Breast reconstructions performed under general anesthesia may last 1-2 hours when a breast implant is used, and 4-10 hours when the patient's own tissue is used, depending on the technique. When a breast implant is used, hospital stay is 1-3 days; in autologous reconstruction with flap tissue, hospital stay is 4-7 days. Within the reconstructed breast tissue and at the site where the patient's autologous tissue was taken, there are silicone-based devices called ‘drains’, shaped like a hose with a hand bulb, which prevent fluid and blood from accumulating in the surgical area. They are removed between 1-4 days, once fluid and blood accumulation has decreased. Removal is a painless, simple dressing-type procedure performed on an outpatient basis. After the drains are removed, the patient may shower. Dressings continue for some time. Although return to daily life after silicone implant reconstruction occurs within a few days, recovery of sensitivity and tightness in the abdomen after autologous breast reconstruction (if abdominal tissue was used) takes up to 1 week. One week later, although most patients can do most of their own tasks, they should avoid heavy lifting, exercise, sexual intercourse, driving, and similar activities for 4-8 weeks. They should be protected from conditions that increase intra-abdominal pressure, such as coughing, straining, constipation, and sexual intercourse. Over time, all the pain and distress endured through surgeries is forgotten. Wounds improve further each day and scars fade. The presence of breast tissue gives the patient who has gone through this process a sense of wholeness, along with the happiness and confidence of having moved beyond the cancer diagnosis.
Other surgeries after reconstruction
Breast reconstruction involves surgeries performed in several sessions. After breast reconstruction, various procedures may also be appropriate to achieve bilateral symmetry, such as flap revision, mastopexy (lift) of the opposite breast, breast reduction, or placement of a silicone implant. Whether done with a breast implant or with the patient's own tissue, breast tissue without a nipple and areola does not give a complete breast appearance. At the patient's request, a nipple and areola can be created by different methods. The nipple can be created under local or general anesthesia using various methods. Some patients find that sufficient breast tissue of adequate size and shape to fill out a bra is enough, and since creating a nipple is not very essential, they do not request nipple reconstruction.
