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;
The 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.