Breast cancer continues to be a major cause of morbidity and mortality in the female population. In a large percentage of patients, mastectomy is part of breast cancer treatment with its well-known physical and mental effects. Therefore, the reconstruction of the removed breast is an integral part of the surgical treatment of breast cancer, because it contributes both to the physical and mental rehabilitation of the patient.

Whether and when breast reconstruction will be performed depends on a variety of factors, the most basic of which are the stage and extent of the disease and the possible additional treatment required. Thus, breast reconstruction can begin either immediately, at the same surgical time as the mastectomy, or later, when the cancer treatment has been completed. More than one stage is usually required to complete the reconstruction of the removed breast, achieve symmetry between the two breasts and reconstruct the nipple and areola complex.

Recovery methods

Various methods are used to restore the breast after mastectomy. The factors that affect the breast reconstruction method depend on the constitution of the body and especially of the patient’s chest wall, the size of the breasts, the availability of tissues in the anterior chest wall, the administration or not of radiation therapy, the general condition of the patient, the age and her desire.

Breast reconstruction methods can be divided into three categories:

1. Breast reconstruction using synthetic materials, i.e. silicone implants.

2. Breast reconstruction from autologous tissues (tissues from the patient’s body).

3. Breast reconstruction with the transfer of autologous tissues and the modern use of synthetic materials.

Breast reconstruction using synthetic materials

In the first category, the reconstruction of the mammary projection, as long as the breast is small and not sagging, is achieved immediately – at the same time as the mastectomy – or later by placing silicone inserts under the muscles of the anterior and lateral chest wall. If the breast is larger, then preliminary stretching of the muscles and skin of the anterior and lateral chest wall is required, which is achieved by using tissue expanders, i.e. inserts with a valve, through which it is possible to gradually fill them with saline and hence the gradual stretching of the overlying muscles and skin. When the stretch reaches the desired size, in a second surgery the tissue expander is replaced by the permanent silicone insert. During this second surgery, the symmetry of the two breasts is checked and restored, in terms of position, size and degree of drooping.

Recently, attempts have been made to place the final silicone insert in the place of the removed breast, i.e. under the skin and subcutaneous tissue, and not in the depth of the muscles of the anterior chest wall, and sometimes with preservation of the nipple and areola complex.
The insert is covered by specially processed titanium meshes. The method shows a slightly higher rate of wound breakdown compared to the aforementioned breast reconstruction method.

Breast reconstruction from autologous tissues

The second category of breast reconstruction methods concerns the transfer of autologous tissues, in the form of either a pedicle flap or a free vascularized flap. In the second case, microsurgery – with a microscope – suturing of the vessels of the flap with vessels of the area to which it is transferred, i.e. the anterior chest wall, is required. Usually these flaps are taken from the lower (subumbilical) part of the abdominal wall and transferred to the mastectomy area to form the removed breast. The advantage of this method is that the reconstructed breast is made entirely of tissue from the woman’s own body and therefore follows all the changes it undergoes during her life (weight gain – loss, etc.) . In addition, the abdominal wall appears improved in terms of abdominoplasty.
In the category of breast (or breasts) reconstruction with autologous tissues should be included the method of autografting fat, which is taken by liposuction from the patient’s own body and injected into the breast area. Pre-stretching of the chest wall tissues with a special externally applied stretcher is required, as well as many – three to four – sessions to complete the breast reconstruction.

Breast reconstruction with the transfer of autologous tissues and the modern use of synthetic materials

In the third category of breast reconstruction methods, autologous tissues are used to regenerate the tissues removed by mastectomy and to improve tissues that remain in the chest wall. At the same time, however, to increase the volume and projection of the breast, a silicone insert is also used. The tissue usually transferred is myocutaneous (muscle and skin) or just the muscle flap of the latissimus dorsi muscle.

As already mentioned, breast reconstruction can begin at the same surgical time as the mastectomy. In the majority of cases, a second surgery is required to achieve symmetry between the breasts. The areola is usually created with a tattoo, while with a small surgery, under local anesthesia, the nipple is restored. The areola and nipple are only reconstructed when the size, shape and symmetry of the breasts are satisfactory.

All methods have advantages and disadvantages. The Plastic Surgeon must be aware and able to perform any of them, so that he can choose the most suitable one for each of his patients.

It is written by
Ekaterini Vlastou MD, FACS (Hon)
Plastic Surgeon
Clinical Director of Plastic and Reconstructive and Aesthetic Surgery HYGEIA