Rebuilding the Breast After Breast Cancer(Breast Reconstruction)

Breast reconstruction procedures can and should be performed for all breast cancer patients who have no medical condition preventing breast reconstruction. Who will have breast reconstruction, its timing and its method are decided together by the General Surgeon, the Oncologist, the Plastic Surgeon and the patient. Every patient diagnosed with breast cancer should ask the doctor who will carry out her cancer treatment to give her information about breast reconstruction.

When breast reconstruction is performed at the same time, in the same operation in which the surgical procedure for breast cancer is carried out, it is called ‘immediate breast reconstruction’; reconstruction performed after waiting for oncological treatment to be completed is called ‘delayed breast reconstruction’. In early-stage tumours, the reconstruction procedure can also be started while the breast is being removed (immediate breast reconstruction). If the stage of the tumour is advanced and radiotherapy is planned after surgery, the reconstruction procedure can be postponed until later. The end of the patient's chemotherapy and radiotherapy is awaited, and frequently the reconstruction process (delayed breast reconstruction) is started after one year. If it is not certain whether she will receive radiotherapy after surgery, an empty tissue expander is placed under the chest muscle during the mastectomy and the inflation process is started after the treatments are completed. In this way the patient is spared an extra operation.

For patients, learning that they have breast cancer is a psychological trauma in itself. On top of this, the loss of their breasts, even if for the purpose of treatment, creates extra psychological, social and physical problems for them. Yet if the shape and tissue of the breast can be provided with a reconstruction method applied during the oncological surgery performed on the patient, patients are protected from this extra stress and trauma. Their compliance with and motivation for subsequent treatment increase. For this reason, performing breast reconstruction is not an aesthetic procedure but an entirely medical necessity that positively affects the patient's health. Breast reconstruction is now accepted all over the world as a part of breast cancer treatment. With a decision taken in 2010, the US Food and Drug Administration (FDA) made it mandatory for all breast cancer patients to be informed about breast reconstruction methods during treatment. Breast cancer patients should ask their doctors for detailed information on this subject.

In patients whose cancer is at a very advanced stage and who have distant metastases, the reconstruction procedure is not started before the disease is definitely brought under control. Breast reconstruction may not be performed in patients who are very elderly, whose general condition is poor, or who have serious health problems such as advanced heart disease, diabetes or vascular disease.

When the cancer is first detected, in patients whose cancer stage is advanced, if radiotherapy and chemotherapy are definitely planned after surgery, the path chosen is to prefer delayed reconstruction instead of early reconstruction, taking the opinion of the breast surgeon as well. The breast reconstruction process can be started 1 year after the surgery and treatment.

The methods used for breast reconstruction are as follows:

• Reconstructions performed using a breast implant
• Reconstructions performed using the patient's own tissues
• Reconstructions in which the two methods are used together

In skin-sparing mastectomies, in which all of the breast skin is preserved, and in subcutaneous mastectomies in which the nipple is also preserved, silicone implants can be placed directly. The implant is placed under the chest muscle. However, this procedure is suitable for a limited number of patients.

If there is also going to be skin loss during the mastectomy, a silicone balloon called a “tissue expander”, which is either completely empty or partly empty and partly filled with silicone, is placed under the chest muscle. About 3 weeks after the operation, once the healing of the tissues is complete, this silicone balloon begins to be inflated with saline injections. The inflation process takes 2-3 months. As the tissue expander inflates, the chest skin over it also slowly expands. This expansion is similar to the growth of a woman's abdomen during pregnancy. The inflation process usually continues until 50% more than the target breast size is reached. The patient is then taken back to surgery, the tissue expander is removed and a silicone implant is placed in its place. It may be necessary to operate on the opposite breast for symmetry.

Patients with small breasts, whose breasts are not very saggy, who do not have much skin loss and who have not received radiotherapy are suitable for implant reconstructions. In addition, implant reconstructions are generally preferred in patients who have had both breasts removed.

Implant reconstructions are simpler procedures than transferring tissue from other parts of the body. The operation is limited to the chest region. After the operation, patients can return to normal life in a much shorter time. Since no tissue is transferred from elsewhere, there is no additional scar. The reconstruction is performed with the original skin of the chest, and problems such as colour match are not experienced. On the newly created breast there is no additional suture scar apart from the mastectomy scar.

The most important disadvantage of the procedure is that a foreign body such as a silicone implant is used. In mastectomy patients, implant-related problems are experienced more than in ordinary breast augmentation patients. Problems such as capsular contracture, implant visibility and rippling are more frequent. Creating symmetry with the opposite side is more difficult with this method. Even if the breasts look symmetrical at first, as time passes the normal breast ages and sags while the silicone side always remains upright, and asymmetries become marked. For this reason, revision procedures are needed more in the long term.

Reconstruction procedures are carried out by transferring skin and subcutaneous tissues from various regions of the body. The tissues are transferred together with the muscle beneath them and the vessels that feed it. The transfer is done either by moving the whole muscle to the chest, or the tissue to be transferred is completely separated from the body and its vessels are connected to the vessels in the chest under a microscope. Tissues transferred in this way are called flaps. In breast reconstruction, flaps are most often prepared from the abdomen and the back:

• TRAM flap: The abdominal tissue below the navel is transferred together with the muscle of the front abdominal wall.
• Latissimus dorsi flap: The wing-shaped muscle located on the back is transferred, together with the skin over it, through the armpit to the chest wall.

Although there are other flaps used besides these, their areas of use are limited.

In patients with severe skin loss after mastectomy, in cases where the skin quality on the chest wall is not good, and in people who have received radiotherapy, their own tissues are preferred instead of a silicone implant. Patients who have given birth and have a belly are suitable for a TRAM flap prepared from the abdomen.

In people who do not have sufficient tissue in the abdomen and who have not given birth, the abdominal region is not preferred. In such patients, tissues transferred from the back can be used. In addition, in those requiring bilateral reconstruction, the first option should be reconstruction with implants.

The most important advantage of reconstruction with abdominal tissue is that no foreign body such as silicone is used, that the reconstructed breast also ages over time like the healthy breast, and that there is less loss of symmetry. In addition, just as in a tummy tuck, the patient is also rid of the excess in her lower abdomen.

The most important disadvantages of this method are that it is a relatively major operation, that it is more painful and that returning to normal life after the procedure takes longer. It also leads to a long scar on the abdomen, but as in tummy tuck operations this scar is designed to remain within the underwear. After the operation the abdominal wall weakens and a hernia may develop. To prevent this, the abdominal wall is always supported with synthetic meshes. Having had this procedure does not prevent the patient from having children in the future. However, reconstructions from the abdomen are not much preferred in patients planning to have children.

Reconstructions performed with tissues prepared from the back are less painful than those prepared from abdominal tissue. The postoperative recovery period is shorter. Postoperative complication rates are lower.

Its most important disadvantage is that the tissue prepared from the back is frequently not sufficient on its own to create the breast size. Especially in patients whose opposite breast is large, it needs to be used together with a silicone breast implant to obtain sufficient volume. It also leads to a long scar on the back, but this scar remains within the bra or swimsuit.

Fat injections in breast reconstruction are a very topical subject recently. In patients without much skin loss and whose opposite breast is small, fat injection can be used on its own. A single session is usually not enough, and several applications may be needed. Apart from this, fat injections are also frequently used as a procedure supporting other methods. The stem cells given together with it make a great contribution, particularly to correcting the adverse effects that occur in the skin after radiotherapy. After the injection the skin softens, its colour turns pinker and the appearance of visible vessels decreases. In reconstructions performed with breast implants, filling the area around the implant with fat injections makes the breast look more natural and feel softer.

Alongside all these benefits, fat injection enriched especially with a cell cocktail containing stem cells is a high-cost method. In addition, the cost will rise further in patients who need more than one application.

Breast reconstruction procedures are generally multi-session operations. The whole process is spread over a period of close to one year. Among these, the major and painful procedure is frequently the first operation. The subsequent procedures are shorter and less painful.

If reconstruction is to be performed with implants, a tissue expander is placed and the opposite breast reduced in the first operation; in the second session the implant is placed and symmetry is achieved. If it is to be performed with the patient's own tissues, the tissue is transferred in the first operation and, depending on the situation, the opposite breast is shaped. In the second operation, small revisions are needed to achieve symmetry.

In all methods, nipple reconstruction is carried out in the third operation. This is a fairly simple procedure and is usually performed under local anaesthesia. When the nipple is being created, the thin projecting part of the nipple can be created and the coloured part then created by having a tattoo done, or alternatively a skin graft can first be placed to make the dark-coloured part and the projecting part of the nipple created in a later session.

Nipple reconstruction is performed when all stages of breast reconstruction are finished and it is absolutely certain that symmetry has been achieved. This is the very last procedure. The nipple is usually reconstructed in the form of a protrusion obtained by suturing the skin in that area onto itself. If the other nipple is large, a piece of it can also be used. The coloured area around the nipple called the areola can be reconstructed either with a piece taken from the other areola or with skin taken from the inner leg. However, the most widely used method is having a tattoo done. It is possible to achieve symmetry by doing a tattoo in the same colour as the other areola. Because it is extremely practical, the most preferred method is having a tattoo done.

Many factors determine which method will be used, such as the condition of your tissues, your body structure, the treatment you have received, whether or not you have received radiotherapy, the stage of your tumour, the size of your other breast, your age and whether or not you have given birth. After all of these are evaluated, the options that can be used are determined. The patient makes a decision on these options together with the doctor. Breast reconstruction is a long process, and at every stage joint decisions are taken through mutual discussion. For this process to be completed successfully, it is extremely important that the doctor and the patient understand each other well and that mutual trust is established. Problems may be experienced at every stage of the procedures. These problems can only be overcome if there is mutual trust.

The doctor has a responsibility towards the patient to present the suitable options, explain their advantages and disadvantages, and give information about how possible problems will be dealt with if they arise. After the patient has also become informed about the method to be applied, she should take part in the decision-making mechanism and guide her doctor.

Breast loss leads to psychological, social and physical problems in patients. With the start of the breast reconstruction process, patients feel that they have taken control of their lives again, and reconstruction helps them overcome the feeling of emptiness and the depression they fall into after breast cancer. For this reason, breast reconstruction should be applied to all patients who have lost a breast unless there is a condition to the contrary.