Breast reconstruction

A request that comes after a hard journey

Requests for breast reconstruction are frequent, and they most often come after a painful and demanding course of treatment. Nothing about it is compulsory: it is decided when you wish, and it can be decided long afterwards.

Until reconstruction, the patient wears a temporary external breast prosthesis. That delay is not wasted time: it lets the treatments finish and the tissues consolidate, two conditions that bear directly on the result.

Immediate or delayed: two timelines

The difference is one of timing. In immediate reconstruction, the plastic surgeon rebuilds the breast during the same operation as the mastectomy. In delayed reconstruction, it takes place later, once treatments are over.

Delayed reconstruction

Delayed breast reconstruction can begin to be considered 9 to 12 months after the end of radiotherapy. Without radiotherapy, a consolidation period of six months appears sufficient.

Immediate reconstruction

In some cases, the mastectomy can be accompanied by reconstruction in the same operation. The patients concerned have a non-invasive in situ or intraductal lesion requiring a mastectomy, but no complementary treatment expected.

This also concerns patients who have previously had breast-conserving treatment and who, for a new lesion, require a mastectomy: in that case there will be no radiotherapy, since it has already been given. Prophylactic mastectomies also benefit from immediate reconstruction.

Three families of techniques

None is good in itself: each answers a situation. The technique is chosen according to the size of the opposite breast, the patient’s build, and the anatomy of the donor sites, back and abdomen.

The implant

It is the most widely used technique in immediate reconstruction, and the one that, in delayed reconstruction, has over the past decade taken over from flap techniques — thanks to anatomical cohesive gel implants, to the refinement of the advancement and fixation of the inframammary fold, and to the contribution of fat grafting combined with implants, before and after reconstruction.

Flaps

The latissimus dorsi flap brings a thick, richly vascularised muscle to the reconstructed breast, with or without an implant. The rectus abdominis flap transfers to the chest a mass of skin and fat taken between the navel and the pubis. These are the techniques of autologous reconstruction, the kind that uses only your own tissue.

Fat grafting

It is used before an implant is placed to prepare the tissues, afterwards to refine the result, as a complement to a flap whose volume falls short, or on its own in exclusively autologous reconstruction. This is the ground on which the practitioner has published most.

A decision that is not taken alone

The case is validated beforehand by a multidisciplinary breast board. In immediate reconstruction, the cancer surgeon performs the mastectomy jointly with the plastic surgeon, who rebuilds the breast in the same operation.

The decision to operate on the opposite breast, like the decision of a prophylactic mastectomy, always goes through that same collegial validation. Your surgeon and your oncologist will advise you: these are delicate decisions, which take account of your history, your age and genetic risk factors.

What comes after the breast mound

Rebuilding volume is not the last step. Two further procedures complete it, and they count as much as the first in the final result.

Reconstruction of the nipple-areola complex is carried out in most cases about three months after the breast mound has been rebuilt. The nipple is recreated by grafting half of the opposite nipple, and the areola is rebuilt by medical dermopigmentation.

Symmetrisation of the opposite breast is common: it may be too small, too large or ptotic. It is carried out during the same operation as the reconstruction whenever possible.

Finally, secondary lipomodelling may be offered from three months onwards to improve the natural feel, the softness and the concealment of the implant.