TYPES OF RECONSTRUCTION

The breast can be reconstructed using body's own tissue, implants or a combination of both. The optimal technique depends on the patient's wishes, physical attributes, and cancer treatment plan. However autologous reconstruction provides the most natural and permanent results and is therefore regarded as a gold standard in breast reconstruction.

VIDEO PRESENTATION OF DIFFERENT TYPES OF RECONSTRUCTION >>>

Considering the high rate of complications in implant-based breast reconstruction including capsular contracture and the need for implant removal, reconstruction with autologous tissue is superior to implant-based reconstructions, especially in patients who receive additional radiation therapy. Although breast reconstruction with body's own tissue is a more complex procedure, with a longer recovery process and additional scars it nevertheless provides a more natural-looking, long-lasting results and the ability to reshape the tissues to the desired perfection in subsequent operations. These are also main reasons for its increasing popularity in the last decades.

Implants

A silicone implant is used to replace the volume of the breast tissue. It is a preferred method of reconstruction in non-irradiated breasts, after preventive mastectomy and if spare tissue for autologous reconstruction is not available or autologous reconstruction is not preferable by the patient.

It can either be done with prior tissue expansion using a tissue expander or with direct implant placement. Direct-To-Implant breast reconstruction may enable a patient to undergo mastectomy and reconstruction within a single procedure, demanding only one general anesthesia.  Patients who are eligible for this procedure are typically non-smokers, have small to moderate-sized breasts, require a prophylactic mastectomy, or have either a DCIS or low-stage breast cancer that does not involve the nipple or areola area. A direct-to-implant reconstruction can be combined with a nipple-areola sparing mastectomy. In this case the procededure is called single stage reconstruction, since other procedures are not planned.

Tissue expansion

A tissue expander is a temporary breast implant device, placed under the pectoral muscle of the chest and gradually inflated over time using saline water (0,9% NaCl). Inflation causes stretching of the remaining muscle and skin above the expander.

Usually, the expansion begins 3-4 weeks after the insertion. Through a tiny valve mechanism located inside the expander, a salt-water solution is gradually injected to fill the expander over several weeks or months. The injection is done in an outpatient setting during routine follow up visits. You may feel a sensation of stretching and pressure in the breast area during the inflation procedure, but most women find it not too uncomfortable. This process will continue until the size is slightly larger than the planned size of the reconstructed breast. After about 2-3 months, during which the skin adapts to the new volume, the tissue expander will be replaced in a second procedure. In suitable candidates, it is replaced with an implant. Alternatively, the patient’s own tissues can be used as a flap to help build a new breast. Flap-based reconstruction is especially suitable for patients who have undergone radiation therapy as part of their cancer treatment plan.

In cases, where there is an adequate amount of overlying skin and tissue after mastectomy the tissue expander can be inserted above the pectoral muscle and immediately filled to some degree to preserve the overlying skin envelope.

Autologous tissue

This form of reconstruction represents the current gold standard in breast reconstruction. It is an excellent alternative to implant reconstruction, especially for patients seeking to recreate a warm, soft, “natural” feel of the reconstructed breast. It gives excellent, lifelong results, with permanent shape and breast appearance.

Advantages:

• Breast shape is reconstructed from patient’s own tissue (skin, fat or muscle). Therefore no foreign, artificial material, which is often the cause of complication is used.
• The feel of the reconstructed breast is more natural, soft and warm, unlike breasts reconstruction using silicone implants.
• The reconstructed breast is permanent. Unlike some implant patients, DIEP patients do not experience increasing breast hardening (capsular contracture) or implant ruptures over time, and rarely need additional surgery once the reconstructive process is complete.

Increasing awareness of complication after silicone breast implants use generated a rising interest in reconstruction using patient’s own tissues (autologous reconstruction).

Tissue transfer in breast reconstructive surgery can be performed in the form of:

• free flaps (in which blood supply has to be reestablished by vascular microanastomosis at the recipient site using microsurgery);
• pedicled flaps (keeping the original blood supply of the transferred tissue intact)
• fat transfer (fat is taken with liposuction from other parts of the body and injected into the breast in a procedure called lipofilling

The tissue is taken either from the abdomen/ tummy, upper thigh, buttocks or back. The selection of optimal donor area depends on tissue availability, patient's wishes and required breast size.

Autologous reconstruction may also additionally be combined with a silicone implant to achieve the best possible result. 

One of the main advantages of autologous reconstruction is the ability to reshape the breast at a later stage to achieve symmetry and the best result possible, using many different techniques.

You can find detailed information about specific procedures in the following section.