The mastectomy causes physical alterations that entail a perceptive alteration of femininity, change in the body scheme, muscular alterations with frequent contractures, spine deviations and psychic alterations with depression, anguish, negative influence in the experience of the disease, alterations in social relationships and with the couple. All this leads to the need to conclude the integral treatment of breast cancer with breast reconstruction.
The first thing we need is to evaluate the risk of local recurrence and the complementary treatments indicated after the primary surgical treatment, especially RT, in order to assess the most appropriate moment for reconstruction and the personalized technique for each patient. We must also evaluate personal and constitutional factors in order to determine which reconstructive technique is the most suitable for the patient: type of contralateral breast, residual deformities from the mastectomy and local RT, constitutional and donor site aspects, general factors such as age, habits such as smoking and medical history such as HT and diabetes.
Timing of reconstruction
- Immediate reconstruction, initiated in the same surgical act after mastectomy, in cases of good prognosis: stage I/II, extensive DCIS and risk reduction mastectomy in germinal mutations. These mastectomies generally do not require adjuvant RT treatment.
- Deferred reconstruction performed after completion of medical oncologic treatments and adjuvant RT and after control of locoregional and systemic disease.
Desirable aspects in breast reconstruction:
- Recreate a natural looking breast, symmetrical with the contralateral breast.
- Eliminate the need for external prosthetic fillers.
- Restore body image.
- Improve the patient’s quality of life (personal, family, social and couple).
Reconstructive options
- Reconstruction with expanders and prosthesis: it is indicated in young women with good skin quality, non-radiated, with small to moderate breast size and slight to moderate ptosis. Generally an expander is placed in a retropectoral submuscular pocket that gives volume and shape, to be replaced later by a definitive prosthesis. Currently there is a tendency to place the prosthesis directly, in cases of skin and nipple areola complex conservative mastectomies.
- Microsurgery (DIEAP, SIEA, SGAP), we generally use the DIEAP with donor area extracted from an abdominal dermograstric flap (hypogastric) with perforating vessels dependent on the inferior epigastric vessels, performing with this tissue a neomama with vascular anastomosis of the donor pedicle to the internal mammary vessels. It is the most commonly used flap in delayed reconstruction with previous RT.
- Axial musculocutaneous flaps (latissimus dorsi and TRAM) are indicated in the case of poor quality local tissues (atrophy, scars), previous radiotherapy (radiodermatitis), expansion failure, no possibility of microsurgery due to unavailability of donor area or patient refusal. The most commonly used is the latissimus dorsi myocutaneous flap that is transferred from the back to the thoracic wall or the pedicled TRAM that transfers the rectus muscle and fat from the abdomen to the thorax, maintaining in both cases its original vascularization.
- Lipofilling, consists of extracting free fat tissue, generally from the abdomen and buttocks and transferring it by puncture, once centrifuged and the serum has been discarded, to fill defective breast areas in conservative surgery or to partially fill the mastectomy bed to favor reconstruction with expanders and prostheses. Its risk is that the transferred fat can necrose and liquefy forming oily cysts and its results are not usually permanent.
For more information, consult a breast surgeon.