Breast Reconstruction

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Breast Reconstruction

Breast reconstruction surgery is an important contribution in normalization of lives of the women who have a breast tissue loss. The breast tissue loss affects patients physically, socially and mentally.
This type of organ loss constantly reminds the patient of the trauma, disrupts the perception of the body, leads to thinking that she is not desired and liked. This causes the deterioration in relationships both within the family and society.
Especially in summer, there are problems with clothes, and many patients who cannot wear bathing suits do not want to go on a holiday. In cases where the other breast is larger, an asymmetry occurs and this causes the disruption of the balance of the body which leads to spinal problems. Externally used silicone prostheses cause problems on the shoulders and neck and adversely affect the skin due to perspiration and contact.

Breast reconstruction after breast cancer increases the quality of life of the patients and makes them feel better both mentally and physically.

When should breast reconstruction be performed?

In early-stage tumours, reconstruction is started during the breast removal. If the tumour stage is advanced and postoperative radiotherapy is planned, the reconstruction process is postponed. The termination of chemotherapy and radiotherapy is awaited and the reconstruction is usually started one year later. If it is unclear whether or not the patient will receive postoperative radiotherapy, an empty tissue expander is placed under the breast muscle during mastectomy and the filling is done after the end of treatments. In this way, the patient is saved from an extra operation.

How is breast reconstruction performed with the patient’s own tissues?

Reconstruction is carried out with the skin and subcutaneous tissues obtained from various parts of the body. The tissues are transplanted together with the underneath muscle and veins feeding them. The transplantation is carried out by transplanting the whole muscle to the breast or the tissue to be transplanted is removed from the body as a graft and its veins are connected to the veins in the breast under a microscope. These types of transplanted tissues are referred to as flaps. In breast reconstruction, flaps are most often taken from the abdomen and back:

TRAM flap: The abdominal tissue under the belly is transplanted with the underlying muscle in the anterior abdominal wall.
Latissimus dorsi flaps: These wing muscles located on the back are transplanted from the armpit to the chest wall with their skin. There are other types of flaps used but their areas of usage are limited.

In which patients is breast reconstruction with their own tissues preferred?

In patients with severe skin loss after mastectomy, in cases where the quality of the skin in the chest wall is not good and in patients who have received radiotherapy their own tissues are preferred instead of a silicone prosthesis. Patients who have given birth are suitable for TRAM flaps taken from the abdomen.
Abdominal region is not preferred for people who do not have enough tissue in the abdomen and who did not give birth. In these patients, tissues obtained from the back can be used instead. In addition, prostheses should be the first choice to be preferred for those requiring bilateral reconstruction.

Is breast reconstruction carried out in a single session?

Breast reconstruction procedures are usually multi-session surgeries. The whole process spreads over a year. Among these, the major and painful procedure is often the first operation. Subsequent procedures are shorter and less painful.

In cases of reconstruction with prostheses, the tissue expander is placed in the first operation and the opposite breast is reduced. In the second session, the prosthesis is placed and symmetry is achieved. If the patient’s own tissue is going to be used, the tissue is transplanted in the first operation and the other breast is shaped pro re nata. The second operation requires minor revisions to provide symmetry.
In all methods, nipple reconstruction is performed in the third operation. This is a fairly simple procedure and is usually performed under local anaesthesia.

Breast reconstruction (reconstruction of the lost breast tissue due to the mastectomy) methods

Two-stage reconstruction with cadaver skin

In the mastectomy procedure, the breast reconstruction is carried out either in single or two stages, in order for the incisions to heal properly and obtain the best results.

In the first stage right after mastectomy, your doctor carefully fixes a special teardrop shaped tissue expander under your pectoral muscle. This expander is filled with some serum to prevent the pressure of the protected skin of on the removed breast during the surgery. Then, a special kind of skin called Dermal Matrix, which is taken from the cadaver and underwent a special procedure with advanced technology, is used to cover, strengthen and stabilize the lower part of the tissue expander that cannot be totally covered by the muscle. The tissue expander is then painlessly and easily filled with serum until it reaches the size decided by you and your doctor during the controls.

At the end of chemotherapy or radiotherapy which may be required, the second stage is planned in which the tissue expander that is placed in the first stage is replaced with a softer and permanent prosthesis.

Single-stage reconstruction with cadaver skin.

Breast reconstruction can sometimes be performed as a single-stage procedure in suitable people. In suitable patients, it is possible to place the prosthesis directly in the first stage after the breast has been removed. Your doctor carefully places the permanent breast prosthesis under the chest muscle (pectoralis major).

A special kind of skin called Dermal Matrix, which is taken from a cadaver and underwent a special procedure with advanced technology, is used to cover, strengthen and stabilize the lower part of the tissue expander that cannot be totally covered by the muscle. If you are interested in the single-stage procedure, you should discuss this option with your doctor.

Reconstruction of the breast with the individual's own tissue.

“Transverse Rectus Abdominis Flap”, which is known as TRAM, is the skin and fat tissue beneath the belly button in the abdomen, is an autologous tissue source for the breast reconstruction. Transverse Rectus Abdominis muscle is located in the lower abdomen between the ribs and the pelvis. Breast reconstruction procedure with the TRAM flap uses the skin, fat, and muscle of the lower abdomen. The TRAM flap method can be ideal for people with a proper body structure, so if you are interested in this method please discuss it with your doctor.

Repair of symmastia (displacement of silicone prosthesis)

What is symmastia?

Symmastia means the abnormal position of the breasts, breast prostheses, the confluence of the breasts in the midline or positioning of one of the breasts towards the midline of the chest. In some cases, prostheses may appear as combined by displacing and joining in the chest.

This condition may develop due to the formation of a very large space for prosthesis during the surgery, and in particular by creating a large space in the middle of the chest cage.

Often, this may occur with prostheses placed under the muscles, but sometimes even with prostheses placed on the muscles.

Previously, the only and best way to correct this was to remove the prostheses and wait for months to heal. Then, in a single session, new prostheses were placed in their new spaces.

Years ago, scientific articles were written on how to correct this situation and the term “capsular contracture” repair was proposed. This term essentially means using the suture to close the cavity close to the middle area and to apply it to both sides and then to replace prostheses at the same time.

In solving this problem, this method was a more primitive procedure; there were times when it worked, but it was a difficult technique to apply surgically and was not popular. If prostheses were on the muscle, they could be replaced under the muscle to correct the problem. However, since the problem usually arises with sub-muscular prostheses, it is not applicable to most patients.

Recently, many surgeons have begun to apply a new surgical technique that is both easier and safer to overcome this problem. This procedure is called a neosubpectoral pocket or new sub-muscular pocket.

Essentially, this operation allowed us to create a new pocket for prostheses by closing the old pocket at the same time. However, in this case, with the repair of the capsule, instead of partially closing the old pocket, we close it completely.

With this surgery, it is possible to solve not only symmastia but also many prosthetic displacement problems and even in some cases, the capsular contracture. This method, which requires an advanced planning and application, is successfully applied by surgeons with a breast reconstruction experience. We also successfully perform these surgeries in our clinic with more than 15 years of breast reconstruction experience.

Even In recent years, we have been able to increase the chances of success by introducing materials such as Acellular Dermal Matrix (specially treated cadaveric skin) or artificial skin to support and reinforce these repairs. Just as the chimney skirt protects the chimney from the leakage of the metal dropper, the artificial skin gives us the opportunity of treatment by using a neosubpectoral pocket and then to strengthen and support with the artificial skin.

In many cases, we use tissue-based patches or artificial cadaveric skin. Recently, however, surgeons have started using biological fascia and synthetic Vicryl mesh instead of tissue-based patches.

In addition to the surgical treatment that can be performed almost always in a single step instead of waiting for a period of time after the removal of prostheses, we usually recommend that you choose a prosthesis that will probably fit better or fill the cavity, which means a smaller prosthesis than the original one. Not always, but in some cases, the problem is not caused by repeated entries to the tissue or the creation of new pockets, but also it may be due to the fact that initial prostheses were large for the female anatomy or the size of the chest cage.

Although the development and diagnosis of symmastia is a disappointing experience for a woman with breast prosthesis, the good news is that experienced surgeons have a chance to safely treat it by means of appropriate methods as described above.

You should try to find self-confident surgeons with a high level of experience and expertise in breast reconstruction to solve this problem.

Revision (correction) of failed breast enlargement surgery with specially treated cadaveric skin.

When the patient wants surgical problems such as bottoming out (cambering of the part under the breast and a sagging appearance), an asymmetrical appearance due to the displacement of the inframammary crease, symmastia (positioning of the breast towards the midline), wrinkling (wrinkles in breasts) or rippling (a wavy appearance in the breast) to be corrected, breast reconstruction surgery is performed. It can also be performed if breast augmentation surgery does not produce the desired aesthetic result.

Specially treated cadaveric skin (Acellular Dermal Tissue Matrix, ADM) called Alloderm can be used to treat this condition. Acellular Dermal Tissue Matrix can also be used in breast augmentation and breast lift. In order to meet the needs of the patient in the above-mentioned complex situations, a personalized systematic plan is developed and implemented.

Treatment of capsular contracture.

The capsule is the membranous tissue formed by the body around the prosthesis after the surgery. It develops in every patient with a prosthesis. However, due to unclear reasons, sometimes, this membrane thickens and hardens. Capsular contracture can be caused by many different factors. Common complaints in individuals depending on the severity and degree of the capsule formation are as follows;

  • Formation of a membrane-like healing tissue that creates hardness around the prosthesis,
  • Compression and displacement due to the pressure of the implant,
  • Disruption of the breast appearance,
  • Sometimes with an accompanying pain.

Although there are many causes, the removal of all or a large portion of the capsule, the emplacement of the new prosthesis, and sometimes the opening of a new pocket and the addition of Acellular Dermal Tissue Matrix (for example, Alloderm) are required. There is always a risk of recurrence of the capsule after. In such cases, different solution recommendations are evaluated.

Revision with the opening of a new pocket under the muscle for the displacement of breast prosthesis

If the patient has capsular contracture (thickening and compression of the membrane around the silicone and the displacement of breast prostheses) or malposition in the used breast prosthesis, the technique of “forming a new pocket under the muscle is a powerful breast prosthesis revision method. It is an effective method in a wide variety of displacement situations such as displacement of the breast downwards or upwards. It is an important method in repairing prostheses which have displaced from the middle or towards the sides.

Before the technique of creating a new pocket under the muscle was improved, the correction of prosthesis displacement was difficult and most of the time although there was no failure, perfect results could not be achieved.

Previously, the “Capsulorrhaphy” technique was used to treat an abnormal pocket cavity, where it was gradually stitched from capsule to capsule until the prosthesis had the correct size and shape. A completely new space is opened in front of the old pocket and behind the pectoralis major (chest muscle). This approach creates a new prosthetic pocket where the new prosthesis will be placed.

The new pocket is positioned directly in front of the old prosthesis cavity, and thus the prosthesis can be placed again in the new position. In order to prevent the breast prosthesis from re-entering the old cavity, the old pocket is partially removed and then completely removed by sutures.

The new pocket under the muscle can be strengthened with the Acellular Dermal Tissue Matrix layer or this repair can be strengthened with the help of a protective mesh that helps to hold the breast prostheses in a new position and keep the new pocket from stretching.

Am I a suitable candidate for breast reconstruction with a new sub-muscular pocket technique?

Breast reconstruction with the new sub-muscular pocket can be performed to most patients with prosthesis malposition. However, this method may not be suitable for women with a very thin tissue. Whether the patient is a suitable candidate for this procedure will be determined by a surgical specialist.

The new sub-muscular pocket technique is especially suitable for patients who require larger and complex corrections, as it is safer and more precise compared to capsulorrhaphy, use of which is usually limited to minor corrections.

Limitations and risks in breast reconstruction with the new sub-muscular pocket technique

The new sub-muscular pocket technique is a good option for any woman who has problems such as post-operation malposition or capsular contracture. A complete capsulectomy may be a better option in some cases of capsular contracture.

A capsulectomy or neosubpectoral approach is a technical issue and depends on the surgeon’s decision. Similarly, when especially covering tissues are weak, malposition can be better repaired with the use of Acellular Dermal Tissue Matrix or the posterior capsular flap supported by the mesh.

Recovery and non-functionality in breast reconstruction with the new sub-muscular pocket technique

The recovery time in breast revision surgery with the new sub-muscular pocket technique is similar to the first breast augmentation procedure. The patient may experience pain and some bruising may occur. As part of the process, a drain can be attached to prevent the excess fluid from accumulating.

The drain is removed as soon as possible, usually about a week following the surgery. Patients may be restricted from some activities the first day but may continue their daily activities. However, they should avoid heavy exercises involving the upper body for about three to four weeks.

With the new sub-muscular pocket technique, reconstruction procedure usually does not cause an extra surgical scar since the incision is made in the same location as the incision of the first breast augmentation procedure.

Results in breast reconstruction with the new sub-muscular pocket technique

In experienced hands, breast reconstruction with the new sub-muscular pocket technique is quite successful in providing patients with the desired results. ADM, usually placed inside the breast pocket during the procedure, strengthens the weak tissue and supports the patient’s tissue renewal.

ADM also acts as an `inner bra` by providing an extra layer of protection and support to the prosthesis. In addition, ADM helps prostheses in producing more natural-looking appearances. Removing the scar tissue, which is common with capsular contracture, helps alleviate the pain experienced by the patient.

Patients suffering from the malposition of their prostheses usually do not have any problems after neopectoral breast reconstruction procedure. However, if a problem occurs again, another pocket can be made more easily, if necessary.

A very popular operation in the world

Breast reconstruction surgery with the new sub-muscular pocket technique is a very popular procedure and receives positive responses from surgeons around the world. It is a very effective treatment for breast malposition and capsular contracture

Many plastic surgeons who are specialized in breast prosthesis reconstruction surgery, recommend breast reconstruction surgery with the new sub-muscular pocket technique for the treatment of malposition and capsular contracture.

Latissimus Flap Breast Reconstruction

Latissimus dorsi is the widest muscle of our body located in the back. The tissue transplantation with this muscle is a breast reconstruction option involving an autologous tissue transplantation. In the Latissimus flap method, the muscle and skin obtained from the back region are used for breast reconstruction.

Skin and muscle are taken from the back and transferred to the removed breast area via a tunnel. Sometimes silicone prostheses are used with Latissimus flap to augment the breast. The Latissimus flap method may be ideal for some selected candidates. Therefore, if you are interested in this method, please talk to your doctor.

Revision in breast reconstruction

After the breast tissue removal and reconstruction, many women may need revision procedures. Revision in breast reconstruction can be made due to creating a nipple, improving asymmetry or deformities, contouring the breast, or treating capsular contracture.

Common procedures include fat injection, replacement of prostheses, breast reduction/removal, symmetry operations performed in the other healthy breast, and capsule surgeries. Some women may also require revision surgeries for other reasons. Revision may also be needed in breast reconstruction later.

Oncoplastic Reconstruction

After the partial removal of the breast (lumpectomy), unconformities in size and shape may occur due to the loss of the breast tissue. This may cause undesired collapses in the breast, or changes in the position of the nipple, especially compared to the normal breast.

Oncoplastic reconstruction attempts to correct these differences by stimulating and shaping the breast tissue for a better aesthetic appearance. For the most part, this may require reduction and lift in the other breast in order to improve the general symmetry and shape.

Author: Doç. Dr. Erdem Güven
We're writing about our patients.

Frequently asked questions about breast reconstruction.

You may need to stay in the hospital for 1-3 nights after the procedure. There may be some swelling in the abdomen and may continue for several weeks. You will have a corset and you should wear it for 3-6 weeks. This will help to reduce the swelling and to assist the healing process of the incision.
After your drains are removed, you can wear a corset-like outfit. Your reconstructed breast may also swell. Usually, stitches that are not apparent along the incisions and dissolve spontaneously are used. It is important to keep the corset in the abdomen where ribs end in order not to prevent the blood circulation in the newly reconstructed breast.
You can get better to maintain your normal activities in about a week. If you do not have dizziness, you can take a walk. Intense exercises, heavy lifting, and abdominal exercises are prohibited for 6 weeks.

You may have pain for a few days and most of the pain will be in the abdomen. The sense of pressure and tingling in your abdomen can last for 2 weeks. You will be given different painkillers to control your pain after the operation. Pain will be easily alleviated with painkillers in the hospital after the operation and it will be reduced until the day of discharge.

Your first postoperative control will be within three to four days after your discharge. In the control, we will monitor your recovery signs by checking the integrity of your incisions and the transferred tissue and your postoperative period will be followed. Then you will come to the weekly check-ups until your drains are ready to be removed. In the meantime, you may feel some discomfort and pressure in your abdomen.

Many patients get nearly 3 weeks of sick leave. If your job requires physical activity, you can use a 6-week sick leave or work avoiding heavy lifting.

You can drive when you stop using sedative painkillers, feel that your mind is clear enough, and feel physically fit for driving.

Usually, two different groups of painkillers will be given to you as prescriptions. You can take one or the other to control your pain. An oral antibiotic is also prescribed.

You will have a sterile strip adhesive tape covering your incisions. Your incisions may get wet. Do not apply any ointment without consulting your doctor. Incisions on the reconstructed breast will be checked by your doctor.

After you leave the hospital, you do not need to do anything until your first appointment.

Bleeding is always a potential risk in surgeries. In the TRAM flap method, blood transfusion is not required as the blood loss is minimized during the operation. However, if you insist on not having a blood transfusion, you should inform your doctor and nurses before the surgery.

When you feel comfortable enough, you can have a sexual intercourse. However, we recommend that you wait 1 week for your incisions to heal. Too much pressure on the incisions should be avoided. Also, avoid manually contact on the reconstructed breast immediately after surgery.

Throughout the abdomen, you will have an incision extending from one side of the inguinal region to the other. Due to drains, there will be two small incisions in the pubic hairline or just above it. You will also have an incision in the belly button. The scars on the breast will vary depending on the amount of the replaced skin.

In order to collect the accumulated fluid after the surgery, there should be two drains in the abdomen and one drain in the reconstructed breast. These drains will be left on you when you leave the hospital. Once a day, you have to measure the fluid and empty the drain.

Before leaving the hospital, the nurse will show you how to do it. The duration of the patient‘s carrying the drains will vary from person to person. They usually stay for 1 or 2 weeks. You can easily conceal them under loose clothes.

You can take a shower after the removal of the drains following the surgery.

Following the surgery, you will be given an abdominal corset to wear. This corset will cover the incision and the lower abdomen. We recommend you to use it for about 3-6 weeks throughout the day. After that, you can start wearing it only during the day to help recovering of swelling and contour healing.

Sedative painkillers can cause constipation. If that is the case, we recommend taking duphalac. This drug is sold in pharmacies without a prescription.

You should be taking the painkiller when you return home, and you should continue as long as you use sedative painkillers. In addition, increasing the intake of fibre-containing food, consuming fruits and vegetables and drinking a large number of fluids will help you in preventing constipation. If constipation turns into a serious problem, we recommend consulting your doctor.

After anaesthesia, some patients suffer from not urinating. However, throughout your stay in the hospital, a catheter can be used to solve the problem. Patients usually can urinate after the complete removal of the drug from their body.

Your doctor usually uses dissolvable stitches. These sutures are not visible from the outside and are absorbed by the body. You will have a stitch holding the drain in place and this stitch will be removed with the drain.

You can travel when you feel physically ready. However, the long journeys within two weeks after the operation may cause discomfort. In addition, in the first 2-3 weeks, we would like to see you in the office on a weekly basis.

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