Breast reconstruction after mastectomy: a new method gives hope to thousands of women. Breast reconstruction after mastectomy

Rbreast reconstruction after mastectomy performed using implants, own tissues, or a combination of both methods. Which method is better? Will the reconstructed breast look natural? When is it better to perform reconstruction, simultaneously with a mastectomy or delayed? We asked these and other questions to the professor, doctor of medical sciences Vladimir Sobolevsky.

- Is a mastectomy mandatory when breast cancer is detected?

In the initial stage of the disease, a mastectomy is not always necessary. If the volume of the gland is large, the tumor is small, located far from the central sections, it is possible to perform a radical resection, that is, to save most of the mammary gland. However, with stage 1 or 2 disease and the need for a mastectomy, in most cases, a subcutaneous or skin-sparing mastectomy can be done. The difference between them is as follows: in a subcutaneous mastectomy, the entire breast skin and SAH are left, while in a skin-sparing mastectomy, the nipple, areola, and breast tissue are removed. If it is possible to save the skin pocket of the breast, then the aesthetic result will be better when performing a one-stage reconstruction. The suture will pass only under the breast or only around the areola, and it does not matter what this pocket will be filled with, with its own tissues or an implant, or a combination of an implant and the latissimus dorsi muscle - aesthetically it is better than a delayed reconstruction

- From the point of view of the aesthetic result, is a one-stage reconstruction (if possible) better than a delayed one?

Certainly better. First of all, due to the fact that during a mastectomy it is not always necessary to remove all the skin of the breast. True, this is not possible in all cases and depends on the stage of the disease and the prospects for treatment. Now, both in our country and all over the world, there is a tendency towards individualization of treatment - not only for breast cancer, but also for other oncopathologies. In the situation of locally advanced cancer involving the skin, preoperative treatment is required and after it a radical mastectomy with removal of all skin, all gland tissue and axillary lymph nodes is assumed to be mandatory radiation therapy after surgery. In such cases, it is better to do the reconstruction delayed, since if it is done immediately, during a mastectomy, the aesthetic result will worsen on the background of radiation therapy.

Does radiotherapy impair the healing process after reconstruction?

Radiation therapy worsens the aesthetic result, but not due to the deterioration of healing, since it is carried out after it, but due to fibrosis and deformation of all tissues that fall into the field of radiation therapy. If reconstruction was made with own tissues, these tissues are sclerosed. If the breast is reconstructed with an implant, capsular contracture very often occurs.

- Radiation or chemotherapy necessarily accompany a mastectomy?

Not necessary. The method of treatment depends on the stage of the disease, the involvement of lymph nodes in the process and the type of tumor immunohistochemistry. If the tumor is highly receptor-dependent, then, as a rule, only hormone therapy is prescribed after surgery.

Breast cancer is a group of diseases that includes more than five completely different diseases. There is a set of diagnostic procedures that allow you to determine cancer, its immunochemical subtype, the level of estrogen and progesterone receptors, the degree of cell atypia, Ki-67, Her-2neu, the prevalence of the process, whether the disease is localized in the gland or is there an interest in regional lymphatic collectors, are there any distant manifestations of the disease. Depending on the immunohistochemistry, tumors are treated differently, with different prospects and prognosis.

After the localization of the tumor is determined, a decision is made: to start with surgery or chemotherapy (if the process is widespread). If the process is localized, we start with the operation and after it, after obtaining the histology of the removed tissues, we determine whether it is necessary to carry out chemotherapy, hormone therapy, or both.

Sometimes the need for radiation therapy is clarified after surgery, after obtaining the final histology. The standard worldwide is to conduct radiation therapy in the postoperative period, if we found more than 3 affected lymph nodes during histological examination. Radiation therapy is performed after healing and removal of sutures. If both chemotherapy and radiation are required, then chemotherapy is given first, and at least 2-3 months must pass before radiation.

- Tell us about lumpectomy - an operation in which only part of the breast with a tumor is removed.

Lumpectomy is rarely done here in Russia. A lumpectomy is an operation in which only the tumor in the breast is removed. This requires mandatory interoperative radiotherapy, and in some cases external beam radiation therapy is still performed. Such operations are indicated for a small group of patients with hormone-dependent tumors up to 2 cm in size. As a rule, these are elderly women. Units for intraoperative radiotherapy are very expensive (40-60 million rubles) and they are installed only in centers that do not have external beam radiotherapy. We do not have facilities for intraoperative radiotherapy. But aesthetically, a small radical resection would be the same as a lumpectomy.

Choosing treatment tactics, we focus not only on Western standards, but on the standards approved by the Ministry of Health. For example, in the initial stages of the disease, if, according to ultrasound, the lymph nodes are not changed, in the West they only do a biopsy of the sentinel lymph node: they take one lymph node under the arm, do an urgent study, and if there are no metastases, they do not remove it. The axillary lymph nodes are a regional area of ​​breast cancer metastasis and very often cancer metastases are detected in them. Until recently, their removal was the standard in the West. Now they are not removed for all stages and forms of cancer.

In our country, unfortunately, according to the standards of the Ministry of Health, in case of infiltrative breast cancer, all lymph nodes under the arm must be removed. This is not always necessary, it is not entirely justified, but it takes time, effort and energy to review and change the standards of the Ministry of Health in the right direction.

- Can the patient refuse to remove the lymph nodes?

No. She may refuse treatment and go abroad for treatment. Our research institute is a scientific center, it belongs not to the Ministry of Health, but to the Academy of Sciences, therefore, in the framework of scientific protocols, in some cases we may not perform such an extensive lymph node dissection.

- Are there situations in which reconstruction is possible only with own tissues, using the TRAM method? Or is there always a choice?

There is always a choice. There are two aspects to the treatment of our patients: medical and aesthetic. If we practically do not discuss the medical part with patients, depending on the stage and type of tumor, they are supposed to receive one or another treatment, then we will definitely discuss the aesthetic aspect with the patient.

The choice of reconstruction method is always a very difficult problem. There is no universal method that would suit all patients. The choice also depends on the treatment plans: on whether it is possible to save the skin during the removal of the gland and in what areas, on the volume of the gland, on the availability of own tissues for reconstruction, on the constitution and somatic condition of the patient.

TRAM is not the only way to reconstruct with your own tissues. There are a lot of areas where you can take your own fabrics, and TRAM is the oldest and easiest method. A simple transposed TRAM flap includes the rectus abdominis muscles and a transverse skin-fat flap. The flap is moved on the muscles to the site of reconstruction. Modern techniques make it possible to use only a skin-fat flap on a vascular pedicle (rather thin arteries and veins that supply blood to this flap). You can use other flaps: gluteal, from the hip, from the back. Now there are microsurgical techniques that are less traumatic than traditional ones. We do not use the abdominal muscles, we take only a fat flap. It is possible to transfer tissue without muscle on microvascular anastomoses from the abdomen, from the inner surface of the thigh, from the upper or lower gluteal region . In the area with excess tissue, we can take them with a minimal cosmetic defect and fill the pocket after removing the breast tissue.

The latissimus dorsi muscle is quite often used in reconstructive operations on the mammary gland. Most often it is used to cover the lower pole of the implant (especially if it is large), while the upper pole of the implant is placed under the pectoralis major muscle. In some cases, the muscle is taken with a small skin area, which can be used to reconstruct the SAH. When reconstructing a gland of a small volume, the skin pocket can be filled with one latissimus dorsi muscle. To do this, you need a small incision (5-6 cm) on the back along the linen.

- Which reconstruction method will make the breast more or less sensitive?

It does not depend on the type of reconstruction, but on whether the nipple and innervation are preserved. Sensitivity is violated almost always. Our task, first of all, is to restore the shape and volume, and, if possible, the consistency of the mammary gland. The choice of method depends on many factors: excess or lack of tissues, where and how much skin can be saved, on the condition of the second mammary gland - after all, symmetry is needed, and in half the cases it is necessary to perform a corrective operation on the other side.

How is symmetry achieved during reconstruction? Is it possible to make an individual implant more similar to the second breast shape?

If we are talking about a woman 20-30 years old with a good volume and shape of the mammary gland, then when performing reconstruction with an implant or expander, we try to create a mammary gland of a spherical shape, good filling. If a woman is operated on with a pronounced ptosis, an empty second gland, stretched skin, a projection of the nipple below the submammary fold, there is no point in trying to create a second similarly ptotic gland. Both in the West and in our country, corrective surgery for the second gland - mastopexy or augmentation - is a common practice.

- How is the incision made for immediate reconstruction and what shape will the suture be?

The incision is made not during reconstruction, but during mastectomy, and the shape of the incision depends on its type. The standard mastectomy incision is a horizontal scar from the sternum to the edge of the armpit.

In the West, mastectomy is done by a general surgeon and reconstruction by a reconstructive surgeon. These two specialists are preparing for the operation together and doing each of their steps. Everything is done by one person. This has its pros and cons. When performing a mastectomy, I can already position the incision in a way that suits me so that after the reconstruction it will be in an aesthetically insignificant area.

- Tell us, please, about the restoration with a tissue expander.

The use of a tissue expander involves a two-stage reconstruction and is performed when both breast tissue and a large amount of breast skin need to be removed. For example, in a locally advanced process involving the skin of the breast, it is necessary to treat it before surgery, then do a radical mastectomy without saving the skin, and then radiation therapy may be needed. Having performed the operation, we can immediately place a tissue expander, conduct radiation therapy, and after its completion, through the built-in or external port in the expander, stretch the skin of the anterior chest wall (filling the expander with saline) to create a supply of skin for the future mammary gland.

It usually takes at least 3 months from the first stage (mastectomy and insertion of the expander) to the second (implantation) for a capsule to form around the expander. The capsule is a valuable plastic material that we work with when replacing the expander with an implant, forming a submammary fold. If the expander is replaced with your own fabrics, it may take less time. In general, the process takes no more than 6 months.

- Does the expander affect the future shape of the breast?

Affects. There are different types of expanders: anatomical expanders take a teardrop shape when inflated, round expanders evenly stretch the skin. The choice is made depending on where you need to stretch the skin - in the lower pole, middle, upper. Expanders differ in width and height of the base, in projection, and are selected individually for each patient.

- Tell us about the filling of expanders and implants. Which manufacturers' products are used in breast reconstruction?

All expanders are filled with saline. The implants are filled with either silicone gel or saline. Mentor and McGhan also produce endoprosthesis expanders, expandable implants: this product combines both an implant and an expander. There is a cavity inside such a prosthesis and through an external port (a tube with a portico), the surgeon can inject a solution that will increase its volume - not much, up to about 150 cm 3. As long as the port is not removed, the volume can be changed. After reaching the desired solution size, the portico is pulled out and the valve is closed.

The choice of implants is great, there are a lot of manufacturers, there are Korean, English, French brands. I have not heard about Russian-made products.

- What implants do you use in your practice?

Various. We have a state medical institution and operations are performed according to quotas issued by the Ministry of Health. Patients do not pay for either implants or expanders, their cost is covered by a quota. Our institute has a government contract with Mentor, and I am satisfied with their products. Basically, the products of manufacturers are oriented to the market of aesthetic surgeons who perform breast augmentation, and they need a wide range of conventional implants, and not expanders and endoprosthesis expanders. The products we need are available from Mentor and 2-3 other companies.

- How predictable is the shape of the breast and how does the chosen reconstruction method affect the shape?

It largely depends on the professionalism and experience of the surgeon. The second factor that can affect the shape is radiation therapy, during which, as a rule, the created gland is deformed. Also, the shape depends on the method of reconstruction. A priori, reconstruction with own tissues is better than with an implant. But according to statistics, reconstruction with the help of implants is more often chosen all over the world, since it is technically simpler, the recovery period after the operation is shorter, there is no additional scar: implants have a number of advantages. However, iron, restored by its own tissues, looks more natural. Its volume and shape change naturally with age, as does the shape of a second, healthy breast. The consistency of such breasts is more natural. In addition, over time, the result only gets better, while the breast restored by the implant will sooner or later need to be operated on again. The consistency of the breast with an implant is denser and it does not change over time, capsular contracture increases.

- Is lipofilling used in Russia for breast reconstruction?

Yes. But not as an independent method of reconstruction. I'm pretty sure that no one except Roger Kouri uses it as a mono-method for reconstruction. But almost everyone uses lipofilling as a method of correction after reconstruction in those places where there was not enough adipose tissue. The procedure is performed on an outpatient basis under local anesthesia, it is safe and gives a good result.

- Tell us about the methods of reconstruction of the SAC.

There are different ways, the choice depends on how the gland itself is reconstructed. If with own tissues, then usually the nipple is made from the same flap according to certain patterns, and the areola, as a rule, is tattooed later. The naturalness of the tattooed areola depends on the tattoo artist. Of course, if the areola is blurry, has fuzzy contours of pigmentation, it is more difficult to recreate it, and in this case it is recommended to make a tattoo and the second areola.

Just as there is no one ideal method for breast reconstruction, there is no one-size-fits-all method for nipple reconstruction. In each case, this is done in its own way. During reconstruction with own tissues, for example, a specially shaped flap is cut out and stitched in a certain way. With a two-stage reconstruction using an expander, the skin is stretched and it is not possible to cut out exactly such a flap, then a piece of synthetic material is placed inside the future nipple instead of its tissues.

- What are the features of mastectomy with SAH preservation and further reconstruction? Is the result in this case the most natural?

The result depends on the shape of the gland and the severity of ptosis. If the ptosis is not pronounced, the projection of the nipple is above the submammary fold, the skin is not stretched, the tumor is far from the nipple and areola, then at the initial stage of the disease we can make an incision in the submammary fold, remove all the glandular tissue under the skin and replace it with an implant or own tissues. If the ptosis is severe, the preservation of the nipple and areola is likely to lead to necrosis of the nipple, and there is no aesthetic sense in this. It is not difficult to get a new nipple and areola tattoo, it will look better.

But in Russia, situations are rare when a mastectomy with preservation of the SAH is possible - we have few patients with the initial stage of the disease. There is no medical examination, people are very irregularly examined. It is possible to detect oncological diseases at the initial stage only with regular examinations of healthy people. The tumor never hurts, it develops from its own tissues. The slightest mastitis after childbirth gives terrible pain and the patient immediately runs to the doctor, and the tumor of a rather large size does not bother, does not manifest itself and the woman does not get to the doctor. We have very little literature for patients, people are afraid to go for an examination: “What if they find cancer in me? I'd rather not go." The task of the state and the media is to convey to people that today breast cancer in the initial stages in 95% can be cured. Previously, after treatment, patients lived for 2-3 years, so the issue of reconstruction was practically not raised. Now, after recovery, patients live a full life, for a long time, the reconstruction is relevant and gives an excellent aesthetic result.

Examples of breast reconstruction after mastectomy

Patient 1 (40 years old)

Delayed reconstruction of the right mammary gland with the Becker expander endoprosthesis 2 years after RME. Photos before and 1 year after reconstruction.

Patient 2 (49 years old)

Bilateral delayed reconstruction of the mammary glands with thoracodorsal flaps and Spectra implants was performed.

Patient 3 (40 years old)

Skin-sparing radical mastectomy with simultaneous reconstruction with a relocated TRAM flap. Photos before and 3 years after reconstruction.

Patient 4 (34 years old)

A subcutaneous radical mastectomy was performed with preservation of the pectoral muscles with simultaneous reconstruction with the Becker expander endoprosthesis and a thoracodorsal flap.

Patient 5 (38 years old)

A delayed reconstruction of the left breast with an expander (stage 1) was performed, then the expander was replaced with an implant on the left and augmentation on the right.

Patient 6 (43 years old)

In 1995, subglandular breast augmentation was performed. In 2013, cancer of the left breast was diagnosed. Left radical mastectomy was performed with partial skin preservation with simultaneous reconstruction of the left mammary gland with an implant and a thoracodorsal flap. Repeated subpectoral augmentation on the right. Then 4 courses of chemotherapy were carried out and endocrine therapy was prescribed.
Photos before treatment and 3 months after.

Patient 7 (40 years old)

A delayed reconstruction of the right mammary gland was performed, prophylactic mastectomy on the left with one-stage reconstruction. Stage 1 - installation of the expander on the left. Stage 2 - prophylactic mastectomy on the left and reconstruction of both mammary glands with a split TRAM flap. Then the formation of the nipple-areolar complex on the right.
In the photo: before the start of treatment, after the second stage, 3 months later, a year after the reconstruction.

All operations, the results of which are shown in the photo, were performed by Sobolevsky V.A.

More and more people are suffering from cancer today. In women, the leading position is occupied by breast cancer. The most effective method of combating the disease is a mastectomy - an operation during which the complete or partial removal of the affected gland occurs. This procedure, although it saves the patient's life, often leads to psychological trauma and depression. A chance to avoid such consequences is breast reconstruction after mastectomy. In most cases, specialists use special prostheses during the procedure, but a number of techniques allow you to cope with the problem without them.

Indications and contraindications

The indication for breast reconstruction is its loss, which occurred in the course of the fight against malignant formation.

If the removal of the gland occurs for medical reasons and is done without fail, then the operation to restore it has a number of contraindications:

• progression of cancer;
• any violations of the immunological status of the patient's body, immunodeficiency states (including HIV);
• temporarily - monthly;
• infectious diseases;
• diseases associated with disruption of the internal organs;
• any chronic liver disease (including hepatitis C);
• blood clotting disorders;
• obesity;
• period after the end of lactation is less than a year;
• age up to 18 years;
• diabetes;
• unsatisfactory condition of the patient;
• the doubt of the woman herself in the expediency of the procedure.

The need for breast reconstruction

The need for breast reconstruction surgery after a mastectomy is due to several reasons:

1. The psychological state of a woman.
2. The resulting imbalance in the load on the thoracic spine (the load is greater on the side where the gland is stored).
3. Secondary changes in the osteoarticular system due to an imbalance in the load on the spine:
   • violation of posture;
   • drooping shoulders;
   • curvature of the spine. It can cause problems in the functioning of the chest organs, namely the lungs and heart.

Preparing for the operation

Preparation for breast reconstruction surgery includes several stages:

1. surgeon consultation;
2. carrying out a number of instrumental and laboratory studies;
3. refusal of alcohol 2 weeks before the operation (so that there are no problems with anesthesia);
4. stop smoking 2 months before the procedure (as it can slow down the healing process).

Reconstruction methods

Modern medicine offers several methods for breast reconstruction after mastectomy:

1. Simple replacement of lost breast volume.
2. Reconstruction using reduction mammoplasty methods:
   • reconstruction through the use of implants;
   • reconstruction using the Brava system;
   • reconstruction through the use of musculocutaneous flaps.

Simple Volume Compensation

Today, doctors use a number of techniques to compensate for the volume of the breast. They are based on the transfer of a piece of breast tissue, its extension or rotation in order to fill the defect. At the same time, the shape of the breast is preserved, only its volume is reduced, therefore, a reduction of a healthy breast is usually required. This technique is effective only if no more than a quarter of the gland has been removed.

Application of implants

This method is used if the pectoralis major muscle is preserved, while the skin and subcutaneous tissue are of sufficient thickness and are characterized by mobility. The procedure itself takes place in two stages:

1. Tissue stretching through the introduction of a tissue expander (it takes 5-6 months), this is the name of a special device designed to stretch the skin and form a cavity for the subsequent placement of the implant. The doctor sets the expander under the skin and, observing certain intervals, fills it with liquid. It is injected with a syringe. The entire procedure is performed on an outpatient basis.
2. Replacing the expander with an implant. The type of implant depends on the filling used. It can be saline solution or silicone gel. At the same time, all prostheses have a shell made of solid silicone, their surface can be both smooth and textured. In shape, prostheses are round and anatomical (in the form of a drop). According to many plastic surgeons, silicone prostheses are preferable because they feel more natural and retain their shape better.

The use of this method has several advantages:

• the operation is less traumatic than the transplantation of the musculocutaneous flap;
• the required volume of skin appears twice as fast as when using a vacuum system.

However, this technique also has certain disadvantages:

• frequent visits to the doctor for an injection;
• unnatural appearance of the gland both by touch and visually;
• the existence of a risk of tissue necrosis over the expander (this can happen if the skin is stretched too quickly);
• prostheses are placed directly under the skin, which can cause ptosis;
• the presence of certain restrictions on the use of a number of implants associated with the density of the gel, which is necessary to achieve the result closest to natural.

Brava system

In addition to the expander, a special vacuum device, the Brava system, can be used to form excess skin. It is a special dome-shaped bowl worn on the chest area. A vacuum is created under it, due to which the skin is constantly in a taut state and stretches over time. The result is achieved after a long time, while wearing the system is required every day for at least 10-12 hours.

The main advantage of this technique is that the procedure is performed simultaneously with liposuction, which allows the surgeon to use not only implants during the reconstruction of the gland, but also the patient's own adipose tissue, in which case scars are not formed. The technique also has certain disadvantages:

• the need to wear the device every day for many months;
• it is difficult to achieve a strong stretching of the skin for an implant that is large;
• there is the possibility of the formation of a vascular network and stretch marks.

Breast reconstruction using this technique takes place in three stages:

1. Preparatory. A woman wears the device for 10-12 hours for several months. This can be done both at night and during the day.
2. Adipose tissue transplantation. With the help of liposuction, the doctor takes fat from places where there is an excess of it, and then injects it into the area of ​​\u200b\u200bthe mammary gland.
3. Final. To increase tissue survival, the Brava system is worn for another 3-4 weeks.

Reconstruction with musculocutaneous flaps

Breast reconstruction after a mastectomy can be carried out using musculocutaneous flaps (they are taken from the muscles of the back or rectus abdominis). This method is used in the following cases:

• skin and subcutaneous fat are thin;
• there are scars;
• large volume of preserved gland.

Application of the thoraco-dorsal flap

For surgery, the doctor may use a thoraco-dorsal flap (a flap taken from the latissimus dorsi muscle). Usually, during this procedure, the patient is placed with an implant, and a skin flap is needed to cover it. This technique gives the doctor more chances to model during the reconstruction of the gland, and the risk of complications is reduced. However, this type of reconstruction also has disadvantages:

• It is difficult to make the breasts look natural, since prostheses are installed during the operation.
• There is a noticeable scar on the back.
• Over time, the musculocutaneous flap atrophies, which reduces the cosmetic effect.

Application of the recto-abdominal flap

Restoring the volume of the lost mammary gland, the doctor can use a musculocutaneous flap from the rectus muscles of the lower abdomen. This technique has a number of advantages:

• It produces the greatest cosmetic effect.
• Often, prostheses are not used during the procedure, which ensures that there are no complications associated with them.
• The constitution of the gland is similar to that of a healthy breast. If the weight of the patient changes, the weight of the gland will change with him.
• Sufficient volume of tissues provides the specialist with many opportunities for modeling.

This procedure also has certain disadvantages:

• long-term rehabilitation;
• the possibility of necrosis of the musculocutaneous flap with its subsequent rejection;
• high invasiveness of the procedure;
• postoperative scars;
• anesthesia for a long time (4-5 hours).

Nipple areola restoration

Complete reconstruction of the breast is impossible without the restoration of the areola. To do this, experts can use different methods:

• reconstruction of the nipple from areola tissue taken from a healthy breast;
• skin grafting from the labia minora (in case of pigmentation);
• reconstruction of the nipple from the tissues that were used in the reconstruction of the breast, and pigmentation with the help of tattooing.

Healthy Breast Correction

When restoring a lost gland after a mastectomy, correction of a healthy breast may also be required, it is necessary to eliminate the asymmetry of the glands. In this case, the doctor can resort to different methods:

• mastopexy;
• mastopexy with gland reduction;
• mastopexy with breast augmentation (prostheses are used for this);
• the use of fillers;
• thread pull.

Complications

After breast reconstruction surgery, the following complications may occur:

• swelling;
• bleeding;
• infection;
• necrosis of the skin over the expander or skin flap;
• scars
• problems that cause prostheses (implant displacement or rotation, capsular contracture).

Recovery period

The recovery period after surgery depends on its type.

The most minimally invasive method is the Brava method. Recovery takes 2-3 weeks, and sick leave is needed only for 3 days. There are no restrictions, except for the refusal of thermal procedures.

If the doctor has chosen a technique using an expander, two operations are performed: the installation of an expander and its subsequent removal and replacement with an implant. After each of them, the patient must fulfill the following requirements:

• limit loads;
• refuse thermal procedures;
• avoid direct sunlight.

When dentures are fitted, women need to wear compression garments. Rehabilitation takes approximately 4 weeks.

The longest and most difficult is the rehabilitation period when restoring the breast with the help of a skin-muscle flap:

• stay in the hospital for about 2 weeks;

Breast cancer occupies a leading position among diseases of the mammary glands. With this disease, the entire affected breast is often removed, that is, a mastectomy is performed. Mastectomy is not used for mastitis, but it can be used in case of purulent inflammation of the mammary gland, as well as gynecomastia. Sometimes a resection of only part of the gland is done - a lumpectomy. After the removal of the affected gland, women often resort to reconstructive surgery to restore the volume and shape of the breast. Restoring the shape and volume of the bust is quite realistic, because modern plastic surgery has in its arsenal a wide range of effective methods of reconstructive mammoplasty.

Breast plastic surgery after removal

Breast plastic surgery after breast cancer is carried out in several stages and requires the use of special equipment. Breast reconstruction is currently based on two techniques that can be used in combination:

• patchwork
• prosthetic

The patchwork technique is based on transplanting the patient's own tissues into the area of ​​the removed breast, for example, muscles taken from the abdominal wall or back. Unfortunately, the patchwork technique is very traumatic and is based on an extensive surgical operation. When taking part of the muscles from the anterior abdominal wall, there is a risk of complications, such as hernias. When using the patchwork technique, a significant scar remains at the site of tissue sampling, and there is also a risk of rejection of the transplanted flaps.

The prosthetic technique for breast plastic surgery after oncology is based on the use of breast implants at the site of the removed mammary glands and is carried out in several stages. Mastectomy and subsequent therapeutic procedures lead to a deterioration in the properties of the skin of the bust: it darkens and thickens. The area of ​​the skin of the bust is reduced, they are not enough to install the implant. To eliminate the lack of skin in the area of ​​the removed mammary gland, an expander is introduced - a special extensible silicone balloon filled with saline.

The expander is placed for a period of 3 to 4 months. In the process of wearing it, the plastic surgeon regularly increases the volume of the expander by adding about 100 ml of saline to it in one session. Replenishment of the expander volume is carried out on an outpatient basis and does not create significant discomfort. This approach allows for gradual stretching of the skin. After the expander has created a sufficient pocket for the implant and stretched the skin, the prosthesis can be placed to achieve breast augmentation after mastectomy and restore the natural shape of the mammary glands.

Placement of a breast implant after a mastectomy is similar to standard breast augmentation surgery with endoprostheses. Installing an implant allows you to achieve symmetry of the mammary glands and restore the natural shape of the bust. For breast plastics after oncology, that is, after partial or complete removal of the glands, both silicone and saline endoprostheses can be used.

At the final stage, the areola and nipple are reconstructed. Various techniques can be used for this, including tattooing, the use of donor tissues, or transplantation of one's own pigmented skin.

Recovery period after reconstructive breast surgery

The rehabilitation process after breast augmentation after mastectomy should be carried out in strict accordance with the requirements of the attending physician. To combat swelling and support the mammary glands during the recovery period, special bras and elastic bandages are used. Breast plastic surgery after breast cancer is a major operation, so returning to your normal daily schedule is only possible after a few weeks after this type of breast plastic surgery. The final result of reconstructive surgery can be seen approximately 2-3 months after the operation.

Combined use of prosthetic technique and lipofilling

The combined use of lipofilling and prosthetic technique for breast reconstruction after oncology allows to achieve improved results. During a mastectomy, even muscles are sometimes removed, so the use of lipofilling allows you to form a pillow that covers the implant, which gives the breast a more natural look. Usually, the application of lipofilling is carried out simultaneously with the increase in the surface of the skin of the breast using an expander. Lipofilling can be carried out in several stages to gradually stretch the breast before implants are placed.

When is Reconstructive Breast Surgery Necessary?

What is the purpose of arthroplasty after mastectomy? Breast cancer is extremely common, and its treatment is almost always accompanied by partial or complete removal of the breast, which worsens the shape of the bust. After a long and difficult treatment for breast cancer, a woman may experience psychological complexes caused by the absence of a breast. The situation is facilitated by wearing a bra with special inserts that reconstruct a symmetrical chest. However, this measure is not suitable for everyone, many women are embarrassed by their appearance without clothes. To eliminate such problems, a full-fledged reconstructive breast plastic surgery is performed after the removal of the mammary gland.

Breast reconstruction is a big deal. During the reconstruction process, the tissues of the back and the anterior wall of the abdomen, the second mammary gland, if its shape needs to be corrected, can be affected.

Typically recoverable:

• volume of skin and subcutaneous fat in the area of ​​the removed mammary gland;
• the volume of tissues around the reconstructed mammary gland in the event that adjacent tissues and the pectoralis major muscle were removed during the mastectomy operation;
• nipple-areolar complex;
• the shape and size of the second breast can be adjusted to improve the appearance of the bust and eliminate asymmetry.

Of all the known methods of plastic surgery, almost any can be used:

• the use of spander and breast endoprostheses;
• moving the skin, subcutaneous fat and muscles to the area of ​​the restored breast;
• lipomodelling;
• laser polishing of scars;
• tattoo of the areola area;
• in some cases, it is possible to use vacuum devices to stretch the skin in the area where breast reconstruction is performed after mastectomy.

As you can see, a plastic surgeon needs a lot of skills to perform breast reconstruction, so such work should not be trusted to unverified people.

What is it for

The absence of a breast is not only a psychological problem. Although in most cases it is psychological discomfort that motivates the majority of patients who decide on plastic surgery.

In addition to the problems associated with the unaesthetic appearance of the bust after a mastectomy, there may be:

• imbalance of the load on the thoracic spine on both sides: where the mammary gland is preserved, the load will be greater;
• secondary changes in the osteoarticular system associated with an imbalance in the load on the spine, which are expressed by a violation of posture, lowering of the shoulders, curvature of the spine;
• consequences of curvature of the spine: disruption of the organs of the chest - the heart and lungs.

Therefore, after a mastectomy, it is not only a way to regain self-confidence, but also an excellent prophylactic against a number of chronic diseases of the cardiovascular and respiratory systems.

Video: Life after a mastectomy

What determines the volume of plastic surgery for breast reconstruction

Not all patients of a plastic surgeon have breast reconstruction operations in the same way. The volume depends on a number of criteria.

• The volume of tissues removed during surgery for cancer.

Depending on the extent of the cancer, different amounts of tissue may be removed.

The simplest situation is the removal of local formations while maintaining a healthy part of the mammary gland. In this case, retracted scars and areas of retraction are formed at the sites of removal of nodes and tumors.

The entire breast tissue may be removed, leaving the skin and subcutaneous tissue covering the breast intact. Relatively easy option for subsequent reconstruction. Currently, this type of surgery for cancer is rare. In most cases, it is used to prevent breast cancer in individuals with a genetic predisposition to develop the disease.

Such an operation was performed by Angelina Jolie, whose mother died of cancer at one time. Endoprostheses are installed in place of the removed glandular tissue. Complete removal of the breast is the most common way to remove breast cancer in women.

In cases where there is a risk of spreading metastases, the entire mammary gland, pectoralis major muscle, subcutaneous fatty tissue of half of the breast is removed in order to remove the lymphatic vessels and lymph nodes, to which lymph flows from the diseased mammary gland. This option is the most difficult for the subsequent restoration of the bust and requires special skill of the plastic surgeon.

• The health status of the patient.

The patient should be able to endure another operation and anesthesia without complications. Here it must be taken into account that contraindications for plastic surgery will be much more stringent than for an operation performed for health reasons (for cancer, for example). And what did not prevent surgical treatment of cancer in the past may become a serious contraindication for reconstructive surgery on the mammary glands.

• The appearance of the second breast and the wishes of the client regarding the future size and shape of the bust.

It only seems at first that there is no life after a mastectomy. Over time, while thinking about and discussing with the plastic surgeon the details of the upcoming reconstructive surgery on the mammary gland, there is often a desire to “put in order” the healthy mammary gland, if there has been a descent, there is a desire to reduce or increase the size of the bust.

One of the reasons why many agree to this is the reluctance to endure another anesthesia in the future, when it will be necessary to carry out a surgical breast lift, reduction or increase.

How can removal be done?

Until recently, it was believed that the best option is to first remove the mammary gland, and conduct a reconstructive operation only a year after the mastectomy.

Some surgeons still believe that this is the best way to prevent the development of metastases and recurrence of cancer. But not all patients are psychologically easy to wait that long. For some, a physical defect becomes so significant that even the fact of getting rid of cancer is no longer encouraging.

Relationships in the family worsen. According to a number of reports by European authors of opinion polls and studies, 70% of marriages break up in the first two years after a mastectomy. As a result, there is no illness, but the quality of life allows you to wish for the best.

Therefore, in most cases, reconstruction is now performed simultaneously with the removal of the mammary gland, if there are no serious health problems and contraindications to extended surgery.

How soft tissues are restored in the area of ​​the removed mammary gland

There are several options for restoring tissue volume in the mastectomy area.

Expander can be used

The expander is a special device that is installed in the area of ​​breast reconstruction for a period of 3 to 6 months. It stretches the skin and forms a cavity sufficient for the subsequent placement of the implant.
Expanders are on the list of products offered by most companies involved in the production of breast implants. The algorithm for two-stage use and a breast implant is shown in the video.

Video: Breast reconstruction (expander + implant)

It is placed under the skin and fills with fluid over time. Liquid is injected with a syringe. The procedure is performed on an outpatient basis.

Advantages of using an expander:

• much less traumatic operation in comparison with the transplantation of the musculocutaneous flap;
• the final volume of skin required for breast reconstruction is reached twice as fast as with a vacuum system.

Disadvantages of using an expander:

• The need for frequent visits to the doctor for injections;
• Unnaturalness of the breast externally and to the touch;
• There is a risk of tissue necrosis (death) over the expander if the skin is stretched too quickly;
• The implant is located directly under the skin, therefore there is a risk of rapid development of ptosis, there are restrictions on the use of a number of implants in terms of gel density, so that the final result is as close to natural as possible.

A vacuum device may be used to form excess skin in the area where breast reconstruction is planned. Developed for such cases. It needs to be worn for a long time. Every day to get the desired result, it must be used for 10-12 hours.

The essence of the method is that a special cup is put on the area of ​​​​the mammary glands, which has the shape of a dome. A vacuum is created under the bowl, due to which the skin is constantly in a taut state and gradually stretches.

The advantages of the method are that:

• performed simultaneously with liposuction;
• the method allows using both implants and transplanted own fat to restore the volume of the mammary gland;
• if adipose tissue transplantation is used, there is no scarring.

The disadvantages of the method are that:

• you need to wear a special device on your chest for many months;
• it is difficult to achieve significant stretching of the breast to a large implant size;
• there is a risk of stretch marks and spider veins.

The whole methodology consists of three stages:

Stage 1 - preparatory. It consists in wearing a vacuum system for a certain period of time every day for 10-12 hours. You can wear the system both day and night.

Stage 2 - transplantation of adipose tissue. Fat is taken from those places where there is usually an excess of it, using the method of liposuction. Adipose tissue is transferred to the breast area with the help of injections.

Stage 3 is the final one. The Brava system must be worn for another 3-4 weeks in order to increase the degree of survival of the transferred adipose tissue.

Musculocutaneous flap transplantation

The flap can be grafted from the back (Latissimus dorsi), or the anterior abdominal wall (rectus abdominis).

Advantages of the technique:

• natural shape and feel of the mammary gland;
• there are no problems associated with the use of implants, such as implant displacement, the need for replacement.

Flaws:

• prolonged anesthesia (4-5 hours);
• very high invasiveness of the operation;
• long period of rehabilitation;
• there is a risk of necrosis of the transplanted musculocutaneous flap and its subsequent rejection;
• significant postoperative scarring.

Combined technique

To restore the breast, a skin flap is used from the buttocks, abdomen or back and an implant.

Restoration of soft tissues around the removed mammary gland.

If an extended operation is performed to remove not only the mammary gland, but also the adjacent soft tissues of the breast, then during reconstruction it is necessary to restore their missing volume from the side of the surgical intervention.

Usually, restoration is performed by transplantation of adipose tissue, which is taken from those places where there is an excess of it.

Ways to restore the nipple-areolar complex

Without the restoration of the nipple and areola, breast reconstruction will be considered incomplete, since it is important for a woman to look good both in clothes and without it.

There are three main ways to recreate the nipple and areola:

• the areola is recreated from the tissue of the areola on the healthy side;
• the skin of the labia minora is transplanted if it is pigmented;
• the nipple is formed from the tissues of the restored mammary gland, and the areola is pigmented with the help of tattooing.

Correction of the second breast

In order to eliminate asymmetry, improve the shape of a healthy mammary gland, a large number of methods are used:

• mastopexy;
• mastopexy with breast augmentation with an endoprosthesis;
• mastopexy with breast reduction.

Such methods are less commonly used, for example, the use of fillers.

Contraindications

• the presence of infectious diseases;
• the presence of a tumor process of any stage and localization;
• serious diseases of the internal organs, in which their function is impaired;
• diabetes;
• blood clotting disorder;
• age up to 18 years;
• less than a year from the end of lactation;
• the general serious condition of the patient;
• obesity;
• doubts about the need and expediency of reconstructive surgery on the part of the patient.

Preparing for the operation

• surgeon consultation;
• laboratory and instrumental examinations to identify possible contraindications to surgery;
• it is forbidden to take alcohol two weeks before the operation, as this can lead to problems with anesthesia and getting out of it;
• it is recommended to stop smoking at least two months before the operation, especially if musculocutaneous flap transplantation is planned, to prevent problems with delayed healing and necrosis.

Complications

Rehabilitation

The time required for the body to fully recover after surgery depends on the extent of this very operation. If we talk about the Brava method, then this is the least traumatic method, which requires a hospital stay of a maximum of three days for the duration of liposuction and adipose tissue transplantation.

Photo report of the operation: mammoplasty after breast cancer October 9th, 2018

In medicine, sometimes you have to make a choice in favor of saving a patient's life, sacrificing its quality in the future. From a rational point of view, this approach looks reasonable, but not everything is so simple from the point of view of the patient. For example, for a woman diagnosed with breast cancer, the decision to remove the breast (mastectomy) is associated with deep feelings about the loss of femininity and sexuality. As a result, an operation that is effective from an oncological point of view has serious psychosocial consequences - personal life worsens, the risk of depression, anxiety disorders and even suicide increases. How to solve such a serious dilemma?

More than 100 years ago, the first attempts at surgical restoration (reconstruction) of the removed mammary gland were made. To date, the possibilities of plastic surgery contribute to the adoption by a woman of a positive decision in favor of radical treatment and to prevent disorders in her personal and social life. Today I have prepared for you a photo report of a breast reconstruction operation by installing an implant in a patient after a mastectomy, and in the next post you will see the continuation of this operation, but already on a healthy breast in order to correct it (mastopexy).

Background of the clinical case
A 45-year-old patient about a year ago, as a result of self-examination, discovered a dense mass in the right breast. However, seeking help from local specialists did not allow establishing the correct diagnosis, probably due to their low oncological alertness.

On the recommendation of acquaintances, the woman turned to Dmitry Shapovalov, an oncologist-mammologist at the Medicine 24/7 clinic, for a consultation:

According to the results of the examination, the final diagnosis was made - stage IIIC breast cancer. Taking into account the significant size of the formation (4 cm), the nature of its growth and the sensitivity of tumor cells to sex hormones, a radical mastectomy was performed with simultaneous removal of the uterus with appendages.

Also, in order to reduce the risk of recurrence of the disease, along with the gland, a skin area with the areola and nipple was removed, where tumor cells could penetrate. However, as a result of this, there is a shortage of skin area, which will not allow in the future to install a permanent implant of the required size. Therefore, to restore the skin area immediately after the removal of the mammary gland, a temporary implant (expander) was installed. Unlike the mammary gland, which is located under the skin, the expander and the future implant are installed under the pectoralis major muscle, which excludes their dislocation in the future. After installing the expander for several weeks, physiological saline is periodically added to its cavity through a special port using a syringe to increase its size. Gradually increasing in size, the expander stretches the pectoral muscle and increases the skin area - a musculocutaneous pocket is formed, into which a permanent anatomical drop-shaped silicone implant will be installed at the second stage of reconstruction.

Thus, during the first operation, a mastectomy and the installation of an expander were performed (the first stage of reconstruction). Within a year after the first operation, several courses of chemotherapy and radiation therapy were performed to prevent the recurrence of the disease. Then the patient was hospitalized for the second stage of reconstruction, to which this photo essay is dedicated.

The second stage of breast reconstruction: installation of a permanent implant
Before the operation, the surgeon applies markings - guidelines for surgical manipulations and future contours of the reconstructed breast:

The operation begins with the excision of the surgical scar formed after the mastectomy:

The expander is accessed through the pectoralis major muscle. The expander itself was encapsulated - the body formed a capsule of connective tissue around it:

The task of the surgeon is to remove the expander, keeping this capsule in order to use it for additional fixation of the permanent implant. To do this, the capsule is carefully separated from the surrounding tissues:

In order to get the expander through a small incision, saline is removed from it:

The empty expander is easily removed from the formed musculocutaneous pocket:

This is what the connective tissue capsule looks like, which the body has formed around the foreign surface of the expander:

Using a scalpel, the surgeon cuts through the tissues to form the natural contours of the base of the reconstructed breast:

A particularly important part of the contour is the submammary fold (the lower part of the contour), the height of which largely determines the beauty of the female breast.

Before the tissues heal, the submammary fold can fall under the gravity of the implant, so this area is strengthened with sutures:

The shape of the formed pocket contours is difficult to assess both from the inside and outside before the implant is installed, so the surgeon resorts to a special technique. Having closed the surgical wound with his hand, the surgeon presses on the cavity with air, the pressure of which straightens the tissues and the contour of the future breast becomes visible from the outside, showing irregularities that need to be improved:

Within a few days after the operation, lymph exudate with an admixture of blood will accumulate in the sealed cavity of the musculocutaneous pocket. This can adversely affect the aesthetic result of the operation, as well as cause infection. To prevent these complications, temporary drainage is installed:

The pocket is formed, strengthened and ready for a permanent implant:

After disinfection, the implant is ready for installation. The matte surface of the implant contributes to its fixation by the surrounding tissues, which gradually grow into the irregularities of the foreign body:

The surgeon places the implant in his pocket and once again controls the obtained contours of the reconstructed breast. Even minimal irregularities can become much more noticeable after the postoperative swelling subsides.

This is how the implant and the lower edge of the capsule look through the surgical wound:

The edges of the connective tissue capsule are sutured:

Then the edges of the surgical wound are sutured:

As already mentioned, the nipple and areola were removed along with the mammary gland. At the request of the patient, in the future it will be possible to perform the restoration of the nipple-areolar complex under local anesthesia. Most often, the nipple is reconstructed from the upper layers of the skin, and the pigmentation of the areola is imitated using scarring and tattooing, which can also hide the remaining scars. Outwardly, such a nipple will be indistinguishable from the real one:

In the next post, the continuation of the operation on the healthy left breast will be published in order to correct it ("lift") and achieve symmetry relative to the right one, and you will also see the result of the operation as a whole. In order not to miss - subscribe to