Reconstructing a breast after a mastectomy due to breast cancer is a complex surgical procedure, and the decision of whether to attempt it is no less complex. The decision to reconstruct the breast is primarily the personal decision of the patient, made in conjunction with the treatment staff, including a plastic surgeon, breast surgeon, and oncologist. In the reconstruction of the breast, the involvement of the woman is an important component in determining her physical and emotional health.
Breast reconstruction is conducted in a number of different ways, and the choice of method is dependent upon the physical condition of the patient and her preferences.
Today, breast reconstruction is performed either immediately, as part of the breast removal procedure, or sometimes several months or years following the surgery. This decision is dependent upon the particulars of the case, the need for ancillary treatments such as chemotherapy and radiation, and the preferences of the patient. Immediate breast reconstruction prolongs the duration of the removal surgery and in some cases makes it more complicated, but it shortens the total reconstruction process and reduces the damage to the patient’s external appearance and body image.
Partial reconstruction of the breast, such as after removal of a malignant lump from the breast, is sometimes possible by using tissue from the residual breast, for the purpose of remolding the structure – a procedure named oncoplastic surgery. Sometimes the defect to the bulk of the breast is too great, such as in cases where the breast is initially small. The need then arises to transplant tissues from other areas, such as a flap from the back (latissimus dorsi) or from the chest, or from more distant sites such as the abdomen (DIEP flap), or buttocks (SGAP or IGAP flap) and transferred to the chest with the blood vessels supplying it, which are in turn connected to the blood vessels in the area of the breast using microsurgical techniques.
Reconstructing the breast by using the patient’s own tissue in most cases enables the construction of a breast with a feel and consistency similar to the natural breast. This is especially true after radiation of the breast, which causes damage to the local blood supply, and to the results of the reconstruction.
Reconstructing the breast by using silicone implants is the most common procedure in immediate and delayed reconstructions. In cases where sufficient skin covering remains, it is possible to reconstruct the breast by introducing an implant under the remaining skin and beneath the pectoralis major muscle. In cases where insufficient skin covering remains, it is necessary to make use of an expandable implant or a tissue expander that is gradually expanded through the injection of physiological saline solution and, in a second procedure, is replaced by a permanent silicone implant. Today, sheets of preserved dermis like Alloderm or SurgiMend are used to strengthen and provide internal support to the implants in the lower part of the reconstructed breast.
The results of immediate or delayed reconstruction are not final, and several months or more are required to reach the final appearance of the breast. This, of course, is influential in determining the best time to complete the reconstruction, by reconstructing the nipple and areola, and matching the reconstructed breast to the healthy one. In cases where a double mastectomy is performed, the reconstruction is more complex, but achieving symmetry is generally much easier to achieve.
Dr. Aharon Amir: Breast Reconstruction[