Breast cancer is one of the most common causes of cancer deaths among women worldwide. Partial mastectomies with breast conserving therapy or complete removal of the female breast with mastectomies leave disfiguring defects. In the past breast reconstruction was not widely offered after breast cancer surgery. This has fortunately changed and in our breast center in Cape Town we not only offer breast reconstruction to all our breast cancer patients but we do most reconstructions immediate in the same session together with the mastectomy. There are different approaches to remove breast cancer surgically which needs to determined for each patient individually depending on the type and stage of the disease. This can vary from simple tumor excision to a full mastectomy.
The removal of the whole breast can include the breast tissue and overlying skin, this is a simple mastectomy or a modified radical mastectomy, if an axillary dissection and removal of lymph nodes is performed simultaneously.
The draining lymph nodes in the axilla are in most cases just sampled with a sentinel lymph node biopsy. If only the nipple and areola is removed but the skin retained, we call it a skin sparing mastectomy. In some instances even the nipple can be spared, if considered safe in oncologic terms. This is called a nipple sparing mastectomy. We are performing breast reconstruction procedures on a weekly and sometimes daily basis and we have become a referral centre for breast reconstruction surgery.
Reconstruction after partial mastectomy / Tumor excision
Breast conserving therapy or partial mastectomy according to specific indications is performed in about 60 – 70% of cases. In these patients a partial mastectomy or lumpectomy is performed and the reconstruction is done immediately if necessary. Most lumpectomies can be done without reconstruction if the defect is small and leaves an inconspicuous defect. If reconstruction is performed immediately during the same procedure as the lumpectomy or partial mastectomy it is called oncoplastic surgery. Typically, the remaining breast tissue gets rearranged on the affected side to give the breast an acceptable and natural looking shape. Simultaneously the other breast gets reduced or lifted to match the reconstructed side. If lumpectomies or tumor excisions are done without immediate reconstruction and they cause asymmetry or contour defect it can be corrected at a later stage by fat grafting or small tissue rearrangements.
Implant / Expander Reconstruction
Implant reconstruction can be performed immediately if there is sufficient skin available to insert a breast implant underneath. The breast implant can be placed subcutaneously, if the amount of skin is sufficient and thick enough to obtain a satisfactory result.
If the skin flap is very thin after the mastectomy it might in isolated circumstances be necessary to place the implant behind the pectoral muscle and sometimes a mesh or acellular dermal matrix is used to keep the muscle in position and to cover the lower and outer part of the implant under the skin.
In a few selected cases we can perform a delayed reconstruction with a breast implant without stretching the skin with a tissue expander beforehand. This option depends on the skin quality and quantity.
Risks and complications of implant and expander based reconstructions are mainly due to the fact that implants are foreign bodies. Our own body tries to separate the normal tissue from the implant surface and forms a capsule around it. In ideal circumstances this capsule will be a thin and soft layer of connective tissue. The capsule can also become thick and fibrotic, leading to a hard, deformed and painful breast. This condition is called capsular fibrosis and can lead to a capsular contracture and resulting breast deformity. Multiple studies and trials have shown that complications are increased after implant based breast reconstructions compared to breast enlargements with implants. The complication rate is the highest if the breast has been or will be irradiated in the context of breast cancer treatment. The mechanisms are not fully understood yet and there is no indication beforehand to determine what patient is susceptible to develop complications during radiation. Treatment of capsular contracture is removal of the implant and capsulectomy. A new implant can be inserted, and if this occurs repeatedly own tissue options should be considered for breast reconstruction. If there is no sufficient skin we first insert a tissue expander under the mastectomy skin to stretch the skin and increase the amount of skin available until we are able to insert a permanent breast implant. This is a two-stage procedure. After the mastectomy the expander is filled with Saline in two-weekly intervals. It is recommended to overfill the expander slightly. Once the final volume is reached we allow up to 2 months for the tissue to settle and then the second stage can take place, with expander removal and implant placement.
In autologous reconstruction we use the patients own tissue to reconstruct one or both breasts. In our plastic surgery center the DIEP flap is the golden standard for autologous breast reconstruction. It has the most consistent and reliable blood supply and it can be combined with a cosmetic tummy tuck procedure. The DIEP flap uses fat and overlying skin to reconstruct the breast and it is not necessary to sacrifice muscle or fascia. It is a micro vascular procedure done with microsurgery under the operating microscope. The tissue is reshaped to adjust to the size and shape of the breast and the abdomen is closed in the same fashion as a cosmetic tummy tuck procedure.
Other flaps that we utilise if there is no sufficient abdominal tissue are gluteal flaps and flaps from the inner thigh. The flap from the inner thigh can be combined with a medial thigh lift procedure. We occasionally use local and nearby fasciocutaneous flaps based on a skin perforator. In patients with very large breasts we sometimes do a skin reduction technique with deepithelialised flaps to reconstruct the breast and use the skin excess for breast volume. Fat grafting as a stand alone technique in a delayed setting can be used for reconstruction, but acceptable results can only be achieved with multiple procedures.
A prophylactic mastectomy is done to reduce the risk of getting breast cancer and is also called risk reduction mastectomy. Risk reduction procedures are performed in patients with a high risk to develop breast cancer. A prophylactic mastectomy of the healthy breast in patients diagnosed with breast cancer is frequently done in young patients or in patients with a strong family history or with a proven genetic predisposition to get breast cancer. BRCA1 and BRCA2 carriers have the genetic predisposition and more than 80% risk of getting breast cancer during their life time. In patients that are BRCA carriers bilateral prophylactic mastectomies are indicated. In most prophylactic mastectomies implant reconstructions are performed and only in few selected cases autologous reconstructions.