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Corrective surgery

• Reconstruction after breast cancer • Tuberous breasts • Nipple correction • Breast asymmetry •

Reconstruction after breast cancer

In France, breast cancer is the most common cancer in women, affecting approximately 1 in 10 women.

The management of breast cancer is multidisciplinary, involving surgeons (gynaecologists, plastic surgeons), oncologists and radiologists.
Treatment usually combines surgery to remove the tumour and medical treatment (chemotherapy, hormone therapy) and / or radiotherapy.

Depending on the type of cancer and its evolution, the surgical treatment can be :

  • either a conservative treatment (lumpectomy or zonectomy) which consists of removing the tumour and some surrounding healthy tissue ;
  • or the complete removal of the breast (mastectomy), which involves removing the entire mammary gland and most less of the skin covering it.

This breast ‘disfigurement’ almost always justifies the use of breast reconstruction. The reconstruction is an integral part of the management of breast cancer.

When is the right time to benefit from breast reconstruction ?

Breast reconstruction can be immediate or deferred :

  • Immediate breast reconstruction is done after the mastectomy during the same procedure. For a better cosmetic result and to avoid a number of complications, immediate reconstruction is preferred for cases where no additional radiation therapy is indicated (in situ cancers) ;
  • The deferred reconstruction is scheduled for at least one year after the end of radiotherapy (for better healing) and at least 6 months after the end of chemotherapy (to be in good condition). The time interval between the breast removal and reconstruction should allow the patient to mourn the loss of the breast.
Techniques for breast reconstruction

Whenever possible, Dr. Laveaux prefers autologous reconstruction, which uses the skin and fatty tissue from the patient because the result is natural and long lasting.

It is necessary to differentiate the total breast reconstruction after the mastectomy from the reconstructive surgery following a conservative treatment.

Breast reconstruction after mastectomy

The plastic surgeon has several objectives :

  • replace skin removed during the mastectomy ;
  • recreate the volume ;
  • recreate the sub mammary fold ;
  • reconstruct a nipple-areola complex;

reconstruction mammaire mastectomie cannes côte d'azurThe latissimus dorsi flap :

The latissimus dorsi is a large and flat back muscle whose function is non-essential. Functional consequences due to the removal of this muscle are negligible. It can be peeled back and survive due to a small vascular pedicle located in the armpit, and be transferred to the breast to be reconstructed in the mastectomy scar. It helps restore volume and serves as a medium in which fat is injected to increase the volume of the reconstructed breast.
It may be used alone (purely as a muscle flap) or used with a skin paddle (myocutaneous flap), to cover the missing skin on the breast, but it causes an unsightly “patch”.
The scar caused by the removal of the latissimus dorsi muscle is concealed when wearing a bra. It is thin if the closing is done without tension.

The abdominal advancement flap :

The abdominal advancement flap allows the transfer of skin by stretching up a part of the excess abdominal skin. In this case, there is no “patch” effect like with the latissimus dorsi flap.
The abdominal flap advancement also can recreate an inframammary fold. Incidentally, it slightly increases the volume and projection of the reconstructed breast.

The lipofilling :

The lipofilling (fat injections) increases the volume of the reconstructed breast, or even both of the breasts. This is an aesthetic improvement to areas that have been liposuctioned.

Breast implants :

Implanting breast prosthesis can restore volume. This method is indicated when an implant is required for two breasts or where fat reserves are insufficient to perform lipomodelage.
In breast reconstruction, anatomically shaped prosthesis covered with polyurethane are recommended for a more natural and long-lasting result.

Reconstruction of the nipple-areola complex :

The areola is reconstructed by a tattoo, by skin graft or simply by using adhesive silicone prosthesis.
The nipple is reconstructed using a small local flap or by grafting half the nipple removed from the other breast.
The reconstruction of the areola-nipple complex is always the last stage of breast reconstruction because the shape of the reconstructed breasts must be stabilised.

Other techniques :

Other breast reconstruction techniques are much more complex and can cause a higher risk of complications. This is the case of the rectus abdominis flap (TRAM) or free flap (DIEP) or other free flaps (buttock, gracilis) These techniques are preferred for rare and special cases.

The surgeon has several methods that are associated together to establish a reconstruction program that suits every patient. This program is established taking into account the wishes of the patient but also the technical possibilities related to the morphology of the patient (shape and volume of “normal” breast, fat reserves related to the whole body).

For a good quality breast reconstruction, 2-3 operations are usually needed. The time interval between the two operations varies between 3 to 6 months.
Broadly speaking, the first operation under general anaesthesia is the most complex (2-3 hours) and allows for a latissimus dorsi flap and / or abdominal advancement flap to be used. The hospital stay is 3 to 5 days.
The following procedures include injecting of fat, harmonising the other breast and reconstructing the nipple-areola complex. They take place under general anaesthesia with the duration varying from 1 to 2 hours. The hospital stay is 24 hours.
Only isolated reconstruction of the nipple-areola complex can be performed under local anaesthesia on an outpatient basis.

Correction of the side-effects of conservative treatment

A Lumpectomy decreases the volume of the breast. Radiation causes skin retraction. Breasts that received conservative treatment may therefore have some unpleasant side effects of depression, inverted nipples, and higher volume loss in one breast compared to the opposite one, …
In almost all cases, the lipofilling (fat injections) will, in one or more sessions, significantly improve the aesthetic result.
In certain rare and more complex cases with significant volume loss and tightening of the skin, the latissimus dorsi flap can be proposed with or without additional fat injections.

Breast Symmetrization

Whatever the type of reconstruction, it is quite common for the non-reconstructed breast to need a surgical procedure in order to achieve good chest symmetry.

This procedure could be a change in breast volume (reduction or augmentation) and / or a change in shape (treatment of ptosis).

Cosmetic breast surgery and cancer

Cosmetic breast surgery (reduction or increase in volume, improvement of the shape) does not encourage the occurrence of breast cancer or any other cancer.

However, the radiological assessment performed before the procedure or analysis of removed breast tissue can sometimes help identify an undetected breast lesion.

Finally, after a breast operation, clinical and radiological monitoring can be made more difficult. This is why a radiological examination is often required after surgery to serve as a reference to the radiologist who can compare this review to future examinations conducted during the life of the patient.

Breast reconstruction and risk of cancer recurrence

Breast reconstruction has no influence on the risk of recurrence of breast cancer. Reconstruction does not increase the risk, it does not diminish it either. Any additional treatments (chemotherapy, radiotherapy, hormone therapy) are possible, as well as post-treatment monitoring.
Exceptionally, the reconstruction allows diagnosis of any recurrence or of early breast cancer in the contralateral breast (in a breast reduction resulting from breast symmetrisation due to the systematic analysis of the removed gland.

Tuberous breasts

Tuberous breasts are a congenital malformation of the breasts.

This malformation of the breast, of unknown origin, appears at puberty. Disfigurement is variable depending on the severity of the disease, ranging from frequently undetectable forms (types 1 and 2) to severe forms (type 3) with major disfigurement.

The function of the breast is preserved allowing the patient to breastfeed.

The tuberous breast is defined by various forms of anomalies :

  • an abnormally narrow breast base at the chest wall with the fold under the breast sitting too high. This gives the impression that the breast is sagging however it is because the breast fold is too high ;
  • a long skin envelope gives the impression of a lack of skin ;
  • a neckline often showing stretch marks ;
  • an oversized areola in comparison to the size of the breast. Sometimes the areola protrudes (areolar protrusion) ;
  • a breast that is often too small (but it may be of normal volume or too large ) ;
  • an asymmetry between the two breasts is very common (70% of cases). Both breasts are usually tuberous but one of the two breasts may be more severely affected than the other.

Tuberous breast syndrome is considered rare affecting of 5 out of 10,000 women. However, the exact impact is unknown and difficult to determine due to a lack of diagnostics.

Minor to moderate forms either do not motivate patients to consult because of their non-debilitating character or surgeons who are not experienced with the condition do not diagnose it.

Psychological impact

The breast is the most visible part of the sexual organs and is the symbol of femininity for teenage girls : well developed, inadequate, balanced, weird … These terms risk being attributed to the whole person during puberty.

Even if it is impossible to define the perfect breast, any big differences from what is considered an “ideal” breast create a psychological and physical anxiety in adolescents. Poor body image can lead to a real psychosocial disability with self-exclusion from activities (sport, recreation), avoidance of medical examinations because of shame felt by having “ridiculously” shaped breasts, concealing breasts with unflattering clothes and an unfulfilling sexual life.

Surgical treatment

Surgical treatment is a real challenge as there is a fine line between cosmetic and reconstructive surgery.

All the techniques used in cosmetic and reconstructive breast surgery can be used and combined in order to best suit the patient (breast implants, breast lift, fat injections,…).

Surgical planning

Because of the impact surgery can have on the body image, patients who require subtle changes should consider being operated on at the end of puberty.

Two exceptions are possible :

  • The presence of significant stretch marks can drive early intervention in order to preserve the quality of the skin ;
  • Insertion of breast implants is a decision that should be taken into careful consideration because of the impact it can have on the future. Thus, it is best to wait until adulthood.

Preference is given to treatment performed in one procedure..

Two surgical phases are required if :

  • the decision to expand the skin with a temporary expansion implant has been made (very rarely) ;
  • deformity is corrected without increasing volume from the end of puberty and an increase is desired in adulthood.

Several procedures are required when having only lipofilling (2-3 sessions usually spaced from 5 to 6 months apart). In all cases, the patient should be made aware of having potential touchups in the months following the initial surgery (enlargement of the areola, recurrence of the protrusion …), usually under local anaesthesia.

Health insurance coverage
For severe or moderate cases, partial reimbursement of the cost of the procedure may be considered upon prior agreement.

Nipple correction

The nipple-areola complex (NAC) or nipple comprises an areola and a nipple. The primary function of the nipple is breastfeeding. It is also a powerful symbol of femininity.

Aesthetic changes can be made.

Increase in size
The increase in diameter of the areola can be done by tattoo.
In the case of very small or inexistent nipples, the nipple can be reconstructed by the techniques used in breast reconstruction. Breastfeeding may not be possible after nipple reconstruction.
Decrease in size (Nipple reduction)

The diameter of the nipple can be reduced by an incision around the areola. This reduction may be isolated or be a part of a broader change in the shape of the breast (mastopexy, mastoplasty for reduction or augmentation, treatment of tuberous breasts).

The size of nipples can easily be reduced by “cutting and removing” of the nipple.

Inverted nipples or invaginated

Inverted (invaginated) nipples correspond to the retraction of nipples into the breast, making them invisible. The nipple may come out when it becomes erect.

This retraction is usually related to congenital shortness of the ducts through which the mammary secretions flow during breastfeeding. Because of their shortness, the ducts draw the nipple inward.
In some cases, this retraction occurs after an infection (galactophoritis) or after plastic surgery of the breast.
The inverted nipples can prevent breastfeeding and / or have an impact on sexual life.

Supernumerary nipples and supernumerary mammary glands

Supernumerary nipples (hyperthelia or polythelia) or presence of extra breasts (hypermastia or polymastia) are related to the lack of regression of breast buds during embryonic life. Several breast buds initially exist along the milk-lines and normally only two should remain.

These supernumerary formations are more or less rudimentary. It could be different types of formations, from a small nipple, often confused with a mole, to almost a normal breast which produces milk.

Accessory mammary glands located at the axillary level are frequent and often confused with an axillary continuation of the breast.

The simple surgical excision of the supernumerary elements makes it possible to resolve this issue.

Scarring is usually minimal and is proportional to the size of the formation that has been removed.

Guidelines of nipple procedures

All cosmetic procedures on the nipple (decrease, increase, inverted nipples, supernumerary nipples) are performed under local anaesthesia (diazepine-induced analgesia) on an outpatient basis. The procedure generally lasts less between 30 and 45 minutes.

The after effects are manageable and painless. Complete healing is achieved within 2 weeks.

Postoperative effects

The after-effects are uncomplicated and not painful. Complete healing is achieved in 2 weeks. Returning to work is possible 24 hours after surgery. Sporting activities can be resumed 15 days after the operation.

Risks of complication

Serious complications are very rare after cosmetic nipples surgery.

Healing may be delayed by a few days but is not serious.

Health Insurance coverage

Health Insurance coverage for inverted nipples or supernumerary nipples can have a partial refund of the total cost of the procedure by health insurance.

Breast asymmetry

All breasts have a certain degree of asymmetry, like the rest of the body, but this asymmetry should not appear obvious at first glance. Asymmetry between the two breasts may refer to their shape, volume and / or their position on the chest.
This asymmetry may appear at puberty and be part of a malformation of the breasts (tuberous breasts, Poland syndrome) or be related to “normal” breasts.
Asymmetry may also occur secondarily as a result of trauma (burned breasts, accident, and assault) or after surgery (removal of a benign or malignant breast tumour).

The asymmetry of the chest, especially when it is obvious and moreover if it is related to a malformation of the breasts, results in serious psychological and functional consequences. Patients can develop a complex and be anxious in their daily lives (sexual life, difficulties finding clothing that fits and having to wear a support bra, stopping certain sporting activities, fear of medical examinations).

Surgical treatment of asymmetric breasts utilises all of the plastic, reconstructive and aesthetic techniques that will be selected and combined on a case by case basis (reduction or increase in breast volume, treatment of breast ptosis, areola modification).

Patients are always very satisfied with the result because they regain their confidence and a better quality of life.

Guidelines for the procedure
Surgical treatment of asymmetric breasts utilises all of the plastic, reconstructive and aesthetic techniques that will be selected and combined on a case by case basis (reduction or increase in breast volume, treatment of breast ptosis, areola modification).
Postoperative effects

The patient usually returns home the day after the surgery as the pain is minimal and fatigue is moderate to none. The first waterproof dressing will be applied at Doctor Laveaux’s office after a few days and then showers can be permitted. A compression bra should be worn day and night for 1 month to support the breasts.

Risk of complications

Thanks to the numerous precautions and the experience of the medical-surgical team, the risk of complications is low after a breast asymmetry surgery. In rare cases, the presence of a bruise may call for an intervention in the operating room during the stay at the clinic. The other complications are much less frequent (scar, infection…). Appropriate care will be taken in the event of a complication.

Before / After

correction asymetrie mammaire à Cannes
Correction de l’asymétrie & ajout de prothèses rondes

correction asymétrie de la poitrine à cannes alpes maritimes
Correction de l’asymétrie

Chirurgie réparatrice des seins, reconstruction mammaire à Cannes - Christophe Laveaux

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