BREAST RECONSTRUCTION

WHAT IS BREAST RECONSTRUCTION OR BREAST RECONSTITUTION?

One of the most successful operations of the plastic surgery is the reconstruction of the breast (breast reconstruction) after mastectomy due to a tumor or other disease. Thanks to new technologies in medicine, surgeons can now create a breast that is very similar to a natural breast. Nowadays, these operations can be done simultaneously with mastectomy. Thus, the patient has a new breast and gets rid of psychological distress arising from the period she did not have a breast, when she gets out of the surgery.

However, it should be kept in mind that breast reconstruction after mastectomy is not a simple operation. There are many options to be decided by you and your doctor. You will find basic information about the operation below; the time of the operation, how it is done, and what kind of results are to be obtained. However, it is not possible to answer all the questions. Therefore, you can be well-informed if you provide one-to-one communication with your surgeon.

WHO IS THE BEST CANDIDATE IN BREAST RECONSTRUCTION?

Almost all mastectomy patients do not have any medical obstacle for breast reconstruction and most patients are also eligible for reconstruction with mastectomy simultaneously. However, the best candidates for breast reconstruction are those patients whose cancers are completely lost thanks to mastectomy. There are many reasons to wait; for example, some patients do not want to have another surgery, while others have difficulty in accepting a cancer diagnosis and they cannot consider breast reconstruction options. Their surgeons may advise some patients to wait, especially as such in the situations where the breast is reconstructed with the patient’s own tissue (flap transfer). Patients may be recommended to wait under the conditions such as obesity, hypertension and smoking.

ALL KIND OF SURGICAL OPERATIONS HAVE SOME UNCERTAINTY AND RISK

Breast reconstruction can be performed in almost every woman who has lost her breast due to cancer. However, some problems can also occur after this operation as it is after every kind of surgery.

Bleeding, fluid collection or anesthesia issues, as the general problems of the surgeon, can also be seen after this operation, but they are rare. For the smokers, wound healing can delay, deteriorate or more scars can occur.   These problems sometimes may require a secondary operation. If prosthesis is to be used, there is rarely a risk of developing an infection within two weeks. For some such cases, it may be necessary to remove and place the prosthesis several months later.

The most common problem, capsular contracture, results from the compression of the prosthesis by the scar tissue around it. This creates the feeling of sclerotic breast. There are several treatment options for capsular contracture; sometimes it may require removing and relieving scar tissue or change the prosthesis.

Reconstruction has no effect on recurrence of the cancer and does not interfere with radiotherapy/chemotherapy. Your surgeon may suggest you to continue periodic mammographies in your normal and reconstructed breasts.

SURGERY PLANNING

You can start to discuss the reconstruction from the time of diagnosis of cancer. Ideally, your general surgeon and plastic surgeon should plan and operate on you together. Once your health assessment is done, your surgeon will give you the best options, considering your age, anatomy, tissues and wishes. Your surgeon should be very honest with you about it. Breast reconstruction after mastectomy can improve your appearance and increase your self-confidence; however, remember that this operation can only improve the outcome, but not to make you reach perfection. Your surgeon should also give you information about anesthesia, the location of the operation and its costs.

PREPARATION FOR OPERATION

Your oncologist and plastic surgeon will have some warnings before surgery; for example, what to eat or not, taking medication, etc. Remember to set one of your relatives to take you home after surgery.

SITE OF YOUR SURGERY

Breast reconstruction usually requires several operations. The first-line is usually performed at the hospital, either simultaneously with the mastectomy or secondarily. Other surgeries may be done in the hospital or your surgeon may choose to do it in one of the surgical centers.

ANESTHESIA

The first operation, i.e. the operation of the breast tissue construction, is performed with general anesthesia. That is, you will sleep during surgery. Secondary operations can also be performed with local anesthesia (with sedation) – you will be awake during surgery, but you will feel relaxed and comfortable. Sometimes there may be some inconvenience.

TYPES OF PROSTHESIS

The outer sheath of the breast prosthesis has a silicone layer and there is also either silicone gel or a mixture of salt water called saline inside it.  In the United States, the Food and Drug Administration (FDA) adopted the use of the prostheses filled with gel in 2006. Bu ise, halen doku genişletici taşıyan kadınları, mastektomi ile eşzamanlı rekonstrüksiyonu seçen hastaları ve jel ile dolu bir protez  kullanılabilir. Prostheses filled with saline and gel is also available for everyone.

SURGERY

There are many options and you need to discuss them with your surgeon.

SKIN EXPANSION

The most commonly used technique is the expansion of the skin and then implantation of the prosthesis. A tissue expander is put under your skin and chest wall muscle after mastectomy. A port, which operates with a lid mechanism, is placed under your skin and then your surgeon inflates your tissue expander by injecting saline into it for weeks or months after surgery. When it is understood that your skin is sufficiently enlarged, the tissue expander is removed with a secondary operation and a more permanent prosthesis is placed.  Some tissue expanders are also designed to become permanent. Areola (brown circle skin around the nipple) and nipple are also reconstructed later. There is no need to expand the skin for some patients and prosthesis can be placed with mastectomy.

FLAP RECONSTRUCTION

As an alternative to the prosthetic method, a breast can be reconstructed by collecting a tissue from the back, abdomen or hip. This is called flap reconstruction. In one type of flap surgery, the skin, subcutaneous fat layer and muscular tissue remain to be bound to the original site to which it adheres with a vascular stem and they are moved to the site where the breast is to be reconstructed with the help of a tunnel under the skin. It can create the breast alone, and prosthesis can be placed beneath this tissue as well. In another type of flap surgery, the tissue is completely separated from the abdomen, back or hip region to which it is bounded and its vessels are stitched to those in the recipient region to provide to sustain them (reconstruction with free flap). The plastic surgeon must also be experienced in microvascular surgery in order to perform this operation, because it is only to sew thin vessels together under a microscope.

Both of the above-mentioned surgical methods are more complex operations than the prosthetic method. There will be scars in places where the tissue is collected from and the breast is reconstructed and the recovery period will be longer than the prosthetic method. On the other hand, the result is more natural in the breast reconstruction which your own tissue is used and there is no concern about the silicone. And sometimes, the shape of your belly can be improved and you can get rid of excess skin and fat, which is another benefit.

SECONDARY OPERATIONS

Several operations are needed in breast reconstruction over time. The first operation is the most complex; the second operations are easier; if the reconstruction method with tissue expander is selected, the tissue expander is removed and prosthesis is placed or nipple and areola reconstruction can be performed. The normal breast usually may be needed to be downscaled, removed or enlarged in order to adapt the new breast to the contralateral normal one. However, it should be kept in mind that scars can also occur in these operations.

POST-OPERATIVE

Your post-operative pain can be relieved with medication substantially. Depending on the size of your surgery, you will be discharged from the hospital within 2 to 5 days. Drains can often be placed in the surgery to prevent the accumulation of fluids and they are removed in the first or second week after surgery. Sutures are removed within 7 to 10 days.

RETURN TO NORMAL

It may take up to 6 weeks to return to normal after mastectomy and reconstruction or only flap reconstruction surgery. It also may be shorter in prosthesis surgery. Reconstruction does not provide you to gain a normal sense, but  some sense can come out over time. Most of the scars may fade over time. However, this period may be 1-5 years and the scars will never disappear completely. As long as the reconstruction is of high quality, you will pay less attention to these scars.

Listen to your surgeon’s advice on when to start exercising and movements. As a general rule, it may be better to avoid sexual intercourse and heavy exercises between 3 and 6 weeks.

YOUR NEW APPEARANCE

Your new breast may look harder, rounder and more flat than the normal one. It may not have pre-mastectomy contour or may not be fully symmetrical to the other breast. You think these differences are so obvious. For many mastectomy patients, reconstruction improves the appearance and quality of life dramatically.