Breast reconstruction
Breast reconstruction is a surgical procedure performed to restore the symmetry and shape of a breast affected by a process that has disfigured it, such as breast cancer, trauma (accident or burns, etc.), or a congenital malformation. The most common cause is reconstruction after having suffered breast cancer. In this case, it may be necessary to reconstruct part of the breast after a lumpectomy (only part of the breast is removed) or after a mastectomy or complete breast removal surgery. Its objective is to restore the shape, size and appearance of the breast, giving women a sense of bodily integrity and helping in the emotional recovery process.
There are different options for breast reconstruction, which can be performed immediately, during the same mastectomy surgery, or delayed, at a later time. These options include breast implants, used to reconstruct the shape of the breast using synthetic or natural materials, or autologous tissue reconstruction, which involves transplanting tissue from the body itself, such as the abdomen or back, to reconstruct the breast in a more natural way.
Breast reconstruction not only helps restore physical appearance, but can also have a significant impact on the self-esteem, confidence and quality of life of women who have faced breast cancer. It provides a sense of emotional closure and empowerment, allowing women to regain control over their body and emotional well-being. It is important to discuss all available options with a specialized medical team to find the best breast reconstruction option for each patient, taking into account their individual needs and preferences.
95% of patients who come to my office after the after-effects of breast cancer want to have their breasts reconstructed:
- The breast is an organ that defines and provides femininity.
- It becomes relevant both in the social relations of our society and in sexual relations.
However, what is important is how the patient feels.
What can plastic surgeons do?
Plastic surgery is considered the branch of surgery that shapes the different structures of the body, both for reconstructive and aesthetic purposes, which are often mixed in the same case.
The breast is one of the areas where we plastic surgeons frequently struggle. It can be affected by:
- Malformations
tuberous breast (malformation that gives the breast a tube shape with large areolas and poorly formed lower poles), significant asymmetry between the breasts, amastia (absence of mammary gland), Poland syndrome (malformation of the thorax, the upper extremity and which also affects the breast)
- Traumas
Burns, traffic accidents or work accidents…
- Breast cancer
The breast may be removed completely or in part, and radiation therapy and chemotherapy may be applied to the body.
Reconstructive surgery The after-effects of breast cancer is one of the areas of action where we plastic surgeons work the most. And remember that it is not only exclusive to women, since 1% of breast cancers appear in men.
¿Es necesaria la reconstrucción mamaria?
Do you need breast reconstruction?
Breast cancer
The risk of a woman suffering from breast cancer in her lifetime is 8%. This means that, on average, 1 in 12 women will suffer from it in her lifetime. The risk increases if the cancer is familial (15-20% of the total) or hereditary (5-10% of the total), where the probability of suffering from it increases to 80%.
Don’t be alarmed at first by this data!
Most (70-80% of cases) appear sporadically. To initially suspect that one has a familial or hereditary risk of breast cancer, it is usually the case that several women in the family (or even men) have suffered from this disease. In other words, having a family member affected (such as a mother, aunt or sister) does not mean that we have a higher risk of suffering from it than the rest of the population.
How do we fight breast cancer?
The survival rate for cancer without metastasis is 90% at 5 years. And thanks to early detection programmes with mammograms and awareness among the population, more and more patients are being diagnosed in these early stages.
Thanks to advances in medicine and surgery, the number of women who die from this type of cancer has decreased by 42% in the last 20 years alone.
We currently fight it with surgery and sometimes local radiotherapy (which is much less aggressive than before). We have to keep in mind that cancer is not always just a local disease, and we have to address it at a global level of the body. Many breast cancers are stimulated by the natural hormones we produce, which is why estrogen and progesterone inhibitors are often recommended.
But the treatments that have really marked a before and after in the global treatment of breast cancer are the so-called “biological treatments”, such as Trastuzumab. These act at a cellular level in a similar way to classic chemotherapy but with almost no significant side effects, affecting almost exclusively the cancer cells. Even so, there are cases in which these treatments cannot be used and classic chemotherapy is still necessary to stop the cancer.
How to recover from the damage suffered after breast cancer?
This is where plastic surgeons intervene in a more active way.
If breast cancer is small and has not spread throughout the breast, it can be treated surgically with a lumpectomy., that is, removing only a part of the breast that contains the tumor. Breast reconstruction in these cases is usually simpler because most of the breast is preserved. It is usually sufficient to transplant fat to the affected breast obtained by liposuction or the use of flaps to fill the empty area in the breast after removing the tumor.
If a complete mastectomy was necessary to treat cancer, that is, removing the entire breast from the woman, reconstruction is usually more complicated. But nothing that a well-trained plastic surgeon cannot handle! Depending on the characteristics of each case, reconstruction of a complete breast may require one or more surgical phases. It can be done with different methods:
- Silicone implants
- Own tissues (autologous reconstruction)
- Both
Also, if the healthy breast is very large or sagging, a breast reduction or lift is usually performed to achieve better symmetry and improve aesthetics bilaterally.
The choice of one method or another will depend on:
- How your skin and tissues feel after your mastectomy and other treatments (for example, breast implants are often a poor choice if you have had radiation therapy).
- Availability to obtain own tissues with which to reconstruct the breast.
- Clinical status, social context and opinion of the patient who prefers a longer or shorter surgical process.
- Availability of technical resources by the medical-surgical team and materials by the medical center where the patient is located. This varies depending on the country, and even according to the region within the same country.
Case 1
Chest reconstruction: after-effects of breast cancer
She was a 74-year-old woman who had suffered from breast cancer. Her right breast was removed and she underwent chemotherapy and radiotherapy.
She was reconstructed using the latissimus dorsi muscle (from the back) and with a breast prosthesis.
After a few years, it reappeared there, so the reconstructed breast had to be removed and a lot more radiotherapy had to be done.
She decided that she did not want any kind of reconstruction. But after a few years she had another relapse, the third rib had a new tumor and that is how she came to my office.
In the overall clinical context, together with the thoracic surgeons, we decided to:
– Remove the first, second and third ribs (the lung was exposed during surgery)
– Remove all skin burned by radiotherapy
– Reconstruction of the chest wall with a TRAM flap
What did we get?
We recovered his anatomy
4 nights of hospitalization
360 minutes
Below is a graphic regarding the intervention: the TRAM flap (transverse rectus abdominis muscle-based flap).
In short, we use the skin and fat from the belly (which we would remove when performing an abdominoplasty) and use it to reconstruct the patient’s chest wall.
We move it up, connecting it to the body with the rectus abdominis muscle (the one in the chocolate bar), since inside it has a very important artery and vein that carry blood to the skin and fat that we have taken to the thorax.
The patient has not had any further relapses and can now continue her life.
Have you suffered from breast cancer?
Frequently Asked Questions
Patients would like to know the exact result of their surgery. While it is true that the results of surgery (and of any medical intervention) have a predictable part (it will depend on the type of intervention planned, the wishes of the patient, and factors that we study in the physical examination such as the quality of the tissues), there is another unpredictable part that can modify the result, such as the underlying genetics of each patient or other factors that we have not been able to identify initially.
Our goal is to minimize these unpredictable factors that may affect the result we leave in the operating room in order to give the patient an idea as close as possible to what they will achieve, but it is impossible to guarantee a 100% result for this reason.
Breast mammograms can be performed without problems in women who have breast implants. We recommend that they be performed 12 months after the operation to prevent inflammation from the surgery from interfering with the interpretation of the test. As long as you notify the doctor who is requesting the test in advance so that it can be scheduled to be performed using the Eklund technique, a maneuver that consists of moving the prosthesis towards the back of the breast, leaving it outside the compression paddle, compressing only the breast tissue to perform the mammogram. There is no problem with doing other tests such as MRIs or flying (the prostheses do not explode). Being a breast implant wearer is even beneficial for breast self-palpation, since the breast tissue is more taut and distributed around the implant and allows for greater sensitivity and specificity when palpating all this tissue.
No, the quality of the materials used to manufacture the breast prostheses we work with has allowed us to reduce the risk of complications associated with these to a very low level. This does not mean that it may not be necessary to replace the prosthesis or remove it during life for some reason, but this is rare. The prostheses used years ago did recommend changing them every 10 years, but thanks to scientific advances this is no longer the case.
No type of plastic surgery is currently linked to an increased risk of cancer.
No. We always try to perform breast reconstruction as soon as possible to reduce the psychological consequences for the patient. However, if this means postponing or modifying the treatment in a way that could affect the health of our patients, we will postpone the reconstruction for as long as necessary. The priority is the health of our patients, that is, curing the cancer.
General anesthesia is always used to ensure patient comfort and to allow the surgeon to work with maximum precision and safety. Full intubation is not usually necessary; a laryngeal mask with mild anesthesia is usually the route of choice for our anesthesiology team. Breast surgery should not be performed with local anesthesia; it is bad practice. Throughout the entire operation, the patient's general condition and vital signs are monitored and taken care of in the utmost detail by our anesthesiology team.
One night's stay is usually the norm. It is preferable to be under medical supervision for the first few hours. Although it is not a long or risky surgery, we have been in an operating room and have received medication. In addition, intravenous medication is useful in the first few hours to maximize the patient's postoperative comfort.
We work with different brands of breast prostheses: Motiva, Silimed, Politech, Eurosilicon, Nagor… None of them are the same as the other, each brand has its pros and cons that must be assessed. We will specifically study your case to choose the breast prosthesis that is best for achieving the result you are looking for.
The answer to this question must be individualized in each case. Even so, it can be said that in most patients the recommendation is to place the prosthesis under the muscle (also called submuscular or subpectoral, since the muscle used is the pectoralis major). Among the most common ways of placing a prosthesis under the muscle, the most commonly used is the dual plane, where 50-75% of the prosthesis is covered by the muscle and 25-50% by the lower part of the mammary gland.
This placement has several advantages: the anatomical structure of the mammary gland is not touched at all, which means that sensitivity and subsequent ability to breastfeed are better preserved, and it is a cleaner surgery, which reduces the risk of infection or capsular contracture.
Placing the prosthesis above the muscle, although it is not common in our normal practice, in certain patients, has certain advantages that must be assessed in each case. Above the muscle it can be done in two ways: subglandular (directly under the mammary gland) or subfascial (under the first layer that surrounds the pectoralis major muscle).
There are several tricks that can help us achieve an aesthetically pleasing neckline.
Choosing the prosthesis: This is the most important thing to be able to create a good cleavage. It is necessary that the width is sufficient to cover the entire thorax and thus be able to correctly occupy the entire area. The shape, level of implantation and size of the patient's previous breast must also be taken into account.
The way in which the pectoral muscle is lifted: this is where the prosthesis is inserted and the muscle itself can help us bring the breasts together.
Internal Bra: With the help of stitches, we fix and close the edges of the prosthesis pocket well to create an internal bra effect.
Lipoinjection: Fat injection into the breast allows for the creation of completely natural volume and avoids long-term aesthetic defects such as rippling (surface irregularities). It allows us to create a beautiful and natural neckline using the patient's own fat.
This is a very common question in consultations, since, as is normal, patients would like to know the exact result of their surgery. While it is true that the results of surgeries (and of any medical intervention) have a predictable part (it will depend on the type of intervention planned, the wishes of the patient, and factors that we study in the physical examination such as the quality of the tissues), there is another unpredictable part that can modify the result, such as the underlying genetics of each patient or other factors that we have not been able to identify initially. Our goal is to minimize these unpredictable factors that may affect the result we leave in the operating room in order to give the patient an idea as close as possible to what they will achieve, but it is impossible to guarantee a 100% result for this reason.
So… in answer to the question: What size bra will fit me? We won’t know the exact size until the swelling has gone down and we have a more or less stable result 3-6 months after surgery.
Did you know that 7 out of 10 women do not know their correct bra size?
30% of consultations about breast pain are due to wearing an inappropriate bra. Wearing the wrong bra size can cause not only discomfort, but also marks and injuries, as well as accelerating the ageing process of the breast.
Types of breast prostheses
There are different types of breast implants available, each with its own unique features and benefits.
The choice of one or another prosthesis It certainly depends on the individual aesthetic goals of each patient, as well as their anatomy and personal preferences. In consultation we work closely with each patient and We carry out a complete study of the shape and consistency of the breast and the shape and size of the thorax to determine the most suitable type of prosthesis to achieve the desired results and satisfy aesthetic needs.
Where can breast implants be placed?
Under the muscle (also called submuscular or subpectoral implant)): This is the majority of our cases. Among the most common ways of placing a prosthesis under the muscle, the most commonly used is the dual plane, where 50-75% of the prosthesis is covered by the muscle and 25-50% by the lower part of the mammary gland.
Above the muscle or subglandular implant (directly under the mammary gland) or subfascial (under the first layer surrounding the pectoralis major muscle). This technique is less common, but in certain patients it has certain advantages that must be assessed in each case.
Postoperative
It is normal to experience pain, swelling, and tenderness in the breasts after surgery. Your plastic surgeon may prescribe pain medication to help manage discomfort for the first few days.
You will notice a pain that is usually described as “soreness”, as if you had gone to the gym three or four days in a row. The pain is usually very well tolerated, especially if you follow the medication regimen that we recommend taking the first week after surgery to the letter. Most patients explain that the discomfort is greater during the first 3 or 5 days, and then it is minimal; although each person has a different pain threshold.
After surgery, a compression bandage may be placed around the breasts to help reduce swelling and keep the breast implants in place. However, if the procedure was minor, the postoperative bra may be put on without a bandage to reduce discomfort for the patient.
The first postoperative hours are spent in the hospital's recovery area, where all vital signs are closely monitored. When the patient has fully woken up from the anesthesia (no longer groggy), the pain and dizziness are under control, and she is therefore in optimal condition, she is taken to her room with her family and friends. There, recovery begins in preparation for returning home. In her room on the ward, the nursing staff will diligently ensure that the patient is comfortable and with minimal discomfort, using the medication prescribed by our anesthesiology team when necessary. The nursing team will help the patient to tolerate the intake of liquids and solids, and walking, and thus ensure a safe return home. The next day we will come to the hospital to visit you, to check that the patient is in good general condition and that there are no complications of any kind in the areas that were operated on. We will consider the possibility of removing the drains and bandages, and if everything is in good condition, we will proceed to deliver the discharge report where we will detail all the postoperative instructions that the patient must follow and the prescriptions that she will need to give to the pharmacy in order to receive the medication that we recommend. In the first week after surgery, pain and dizziness are rare, but there are specific times when they can appear and you have to be prepared.
During the first three months (more pronounced during the first month) the breasts will appear higher and larger due to postoperative edema or swelling. It may even be that one breast is more swollen than the other and therefore appears larger (there are patients who have this swelling greater in one breast than in the other and it varies depending on the week and from one breast to the other) giving a sensation of asymmetry or deformity. After three months we have fairly stable results. The result of cosmetic surgery should not be considered definitive until a year has passed since the day of the intervention.
We have to consider them our allies, since they remove the liquid that causes a lot of inflammation if it stays inside and can even increase the risk of complications. They are a nuisance, but there is nothing worse than that. In many of our interventions we leave them, at least until discharge from the hospital. We always leave them longer in abdominal and back surgery than in breast surgery.
You can move your arms to do activities that do not require effort. The important thing is not to lift them or lift heavy weights. Normally we allow you to lift your arms from the second postoperative week, until the surgery is well healed on the inside and movement cannot affect it. And finally, you can lift heavy weights from the fourth postoperative week.
It depends on the type of job. Normally, we allow you to start computer work (secretarial work, IT, telecommunications, etc.) two weeks after surgery. Jobs that involve driving or a lot of movement usually start after three weeks.
We usually allow driving from three weeks postoperatively.
We recommend spending the first five to seven days postoperatively at home, after which we allow going out for a coffee or visiting family or friends. Driving or taking long walks from three weeks postoperatively. Sports such as going to the gym or running from four weeks postoperatively. Intense sports such as climbing, swimming, triathlon… from six weeks postoperatively.
Most stitches are subcutaneous or intradermal, that is, they are under the skin, they go inside. We do not normally leave external stitches (only those at the ends of the intradermal suture). If there is a need to leave an external stitch, we normally remove it after 7-15 days.
Unless there are any conditions that require a longer period of wear, we usually recommend wearing the sports bra for a month, both day and night.
