Türkçe 
Breast cancer is the second most common cancer, after skin cancer, afflicting women. Statistical data prove that globally one in eight women will suffer breast cancer at one stage in her life. According to the US-American Cancer Association, 1.3 million cancer cases are registered every year, with 465,000 reported deaths. Screening programmes have reduced the death rate and extended live expectancy. Improvement of the quality of life after cancer diagnosis and treatment is therefore an issue of particular importance.
Breast reconstruction plays an important role in the normalisation process after cancer-related mastectomy. This radical surgery does not only leave physical traces but also causes a psychological trauma with consequences for the sufferer’s social life. The missing organ constantly reminds patients of the trauma they have suffered and impairs body perception. Patients may feel unwanted or even rejected, with all the negative consequences for their family life and social relationships. Their choice of clothing becomes more limited, in particular in the summer, and they may shy away from swimming in public places. The asymmetry caused by the amputation becomes the more pronounced the larger the breasts, and the associated imbalance may result in postural defects. External silicone prosthetics must be supported, and may affect neck and shoulder. Constant contact of plastic on skin can cause skin irritations. A breast reconstruction can help patients to regain quality of life, rebalance the body and its appearance, and bring relief to the mind as well.
Breast reconstructions are meanwhile recognised all over the world as an integral part of cancer therapy. With a decision in 2010, the American Food and Drug Administration (FDA) has made it compulsory to inform all breast cancer patients about reconstructive surgery during their therapy. Affected women should request detailed information from their surgeon.
Frequently asked questions about breast reconstruction:
Who is a good candidate for breast reconstruction?
Every mastectomy patient can have a breast reconstruction, provided no medical condition prevents it. In consultation with the general surgeon, the oncologist and the plastic surgeon, the patient decides about the modalities of the operation, and the method to apply.
When should the operation performed?
If mastectomy is performed at an early stage of cancer development, reconstruction can start immediately. If the cancer was in an advanced state, and if radiotherapy is scheduled as further treatment, reconstruction must wait until radiotherapy, and possibly chemotherapy, have been completed. On average, this means you have to wait one year. If the application of radiotherapy is not certain, a so-called tissue expander can be placed under the breast muscle already during mastectomy; this saves the patient one operation. The expander is used to stretch the tissue to prepare it for implant insertion.
Who is not a good candidate for breast reconstruction?
If the cancer is already in an advanced state when it is detected, and if radio- and chemotherapy have been agreed and scheduled, reconstruction surgery should be postponed for one year. The decision should be taken in consultation with the surgeon. If the cancer is very advanced and has already spread, the priority should be stabilisation of the patient’s condition before reconstruction is considered. Breast reconstruction surgery may be no good choice for older patients, patients in bad health, patients with advanced heart diseases, diabetics and patients with vascular diseases.
What breast reconstruction methods are available?
The following principle methods are used:
- Reconstruction with implants
- Reconstruction with the patient’s own tissue
- Reconstruction with implants and own tissue.
How is the reconstruction with implants performed?
If the entire breast skin is preserved during mastectomy, or if subcutaneous mastectomy preserves the nipple-areola complex, implants can directly be placed under the breast muscle. However, this method can only be applied in a limited number of patients.
If mastectomy is accompanied by loss of skin, a tissue expander – an inflatable silicone balloon – is placed under the breast muscle. Three weeks after the operation, when the healing process of the tissue is completed, the balloon is stepwise filled with a salt solution to expand the skin. The entire procedure takes 2-3 months. The procedure is continued until 50% of the desired breast size has been attained. Then, in another operation, the balloon is replaced by a silicone implant.
For reasons of symmetry, the healthy breast is often reduced and lifted. This is usually done during the expander placement operation.
Who is a good candidate for reconstruction with implants?
The method is ideal for women with small and relatively firm breasts who have lost relatively little skin in the cancer operation, and who have not undergone radiotherapy. The method is also recommended for patients with bilateral mastectomy.
What are the advantages and disadvantages of reconstruction with implants?
They are easier to perform than tissue transplants, and the intervention is restricted to the breast area. Women can return to their normal life after a relatively short recovery process. Since no tissue needs to be removed elsewhere in the body, no additional scars occur. In the reconstruction procedure, breast skin is used, avoiding a colour mismatch. Besides the mastectomy scar, no new incision is necessary.
The main disadvantage is the use of a foreign material. Mastectomy patients are more sensitive to implants than healthy persons. Implant-related complications include capsular contracture, visibility of the implant, rippling, etc. To achieve a symmetric appearance is also not easy. Over time, asymmetries may develop due to the fact that the natural breast is subject to ageing and loosening of the skin while the artificial breast remains firm. This process requires surgical revisions in the long term.
How is reconstruction with own tissue performed?
In the tissue grafting process, skin-muscle flaps, including blood vessels, are taken from suitable locations on the body and transplanted onto the chest to replace the breast. The blood vessels are stitched together under the microscope. The flaps are usually cut from the belly or the shoulder. The most common are the
- TRAM flap (short for Transverse Rectus Abdominis Myocutaneous flap), which is cut from the underbelly, and the
- latissimus dorsi muscle flap (LDM flap), taken from the back.
The LDM flap can be cut from the shoulder and repositioned to the front while still connected to its supplying blood vessels under the arm pit.
Flaps can also be taken from other locations on the body, however, their use is limited.
Who is an ideal candidate for breast reconstruction with flaps?
Women who have suffered high skin loss due to the mastectomy or whose skin quality is not good or who have received radiotherapy should opt for a tissue transplant instead of an implant. Women who have developed a belly after childbirth are suitable candidates for a TRAM flap. Otherwise, the flap is preferably taken from the back. In case of bilateral mastectomy, however, implants are the first choice.
What are the advantages and disadvantages of a TRAM flap reconstruction?
The greatest advantage is that the body does not reject its own tissue. Also, a tissue graft ages naturally just like the healthy breast, which means a reduced symmetry problem.
The severity of the transplantation process, which is also quite painful and needs longer to heal, is the main disadvantage. Flap removal in the abdomen causes a scar. But it can be placed deep enough to be hidden under clothing. But the abdominal wall is weakened and can develop a hernia (rupture). It must therefore be strengthened with synthetic material. The operation does not prevent a later pregnancy. But if you plan to have children, the flap be better taken from another location.
What are the advantages and disadvantages of a LDM flap reconstruction?
The removal of the flap causes less pain, the healing process is faster and the probability of complications is lower.
On the other hand, the size of the flap is often not sufficient to replace the breast entirely and needs to be complemented with an implant. This procedure also leaves long scars, which can, however, be hidden under a bathing suit or a bra.
Are breast reconstructions combined with fat injections?
Fat injections in connection with breast reconstruction procedures are a current topic. In cases of minor skin loss as a result of the mastectomy, small breasts can be reconstructed with fat injections alone. Usually, this procedure requires several injections. They are also frequently used to complement other methods. The stem cells contained in the fat tissue have a positive effect in particular after radiotherapy. The skin becomes smoother and rosy, and the veins in the skin become less visible. Combined with implant reconstructions, fat injections help to restore a natural appearance.
Is a single operation sufficient for breast reconstruction?
In general, breast reconstruction is a sequence of operations and may take up to one year. The first surgery is usually the most comprehensive and most painful. The follow-up operations are shorter and less painful.
With the first surgery, the tissue expander is implanted and the healthy breast is reduced in size. During the second intervention, the implant is placed and symmetry restored. If tissue grafting is the preferred method, this is performed during the first surgery session. The second phase is dedicated to symmetry and small-scale revisions. In the third session, the nipple-areola complex is reconstituted. This is a relatively simple intervention and requires only local anaesthesia.
When and how is the nipple-areola complex reconstituted?
After the actual breast reconstruction, including symmetry revisions, has been finalised, the nipple-areola complex is added. It is the last surgical intervention. For this purpose, the skin is shaped to resemble the complex or, if the healthy nipple-areola complex is large enough, a section is transplanted. For the areola, the plastic surgeon may take part of the healthy areola or a piece of skin from the inner side of the thigh. The most common method, however, is a tattoo. A tattoo on both sides creates a symmetric impression.
What are the main criteria for the decision on what breast reconstruction method to use?
The decision is based on the condition of the tissue, on the patient’s constitution, whether radiotherapy was applied or not, the status of tumour development, breast size, age, childbirth, and other factors. The advantages and disadvantages of the individual methods are evaluated jointly with the patient before a decision is taken. It is a long and rather difficult process, and after every stage surgeon and patient decide how to proceed. A successful reconstruction requires an open exchange of views and, most of all, mutual trust because there is always a risk of complications.
What are the consequences of a decision against breast reconstruction?
Mastectomy causes physical, psychological and social problems for the affected women. To begin breast reconstruction gives patients a new sense of purpose, of again gaining control over their lives. It helps to overcome the feeling of emptiness, and depression. Therefore, women who have to undergo mastectomy are strongly advised to accept breast reconstruction.
