BREAST AND THORAX
(return to index)
Currently, breast reconstruction after mastectomy is an integral part of the health care that should be offered to an oncological patient, and should only be excluded when the patient expresses her will not to perform it. This is due to the fact that there is a possibility of a significant improvement in the quality of life of the patient, and there is now great confidence in a very satisfactory result compared to the situation of absence of breast. The timing of surgery should respect the timings of oncological treatment, namely with regard to the need for chemotherapy or radiotherapy, the latter almost always resulting in a loss of tissue quality.
Regarding the therapeutic options, the reconstruction with autologous tissues results in the best aesthetic result, resulting in a new breast with shape and consistency closer to the original and maintaining the symmetry in the longer term, while also being able to follow the weight changes of the patient. Preference is given to reconstruction using the abdominal tissues as a donor site, especially DIEP free flap (but also TRAM pedicled flap in some cases), but we can also elect other flaps, such as the latissimus dorsi (back muscle) myocutaneous flap. The advantage of abdominal flaps is that they have a texture closer to the breast texture, the result obtained in the belly (donor site) in almost everything resembles an aesthetic tummy tuck (although the scar sometimes cannot be so close to the pubis, but still inside the clothing) and in the case of DIEP free flap, the loss of resistance of the abdominal wall is very reduced, so the risk of hernias and loss of abdominal strength is minimized. The latissimus dorsi flap, however, uses the skin and muscle of the back as a donor zone, being a recourse technique in cases of revision or when the abdominal tissues cannot be used; it is a procedure with great reliability, although usually the aesthetic results of techniques with abdominal tissue are superior. Due to the complexity of these procedures, hospitalization is expected for at least 3 days. The return to the professional activity can take a few weeks, and exertion must be avoided during the first 6 weeks. The results tend to be very long lasting.
However, not all patients have indication for reconstruction with autologous tissues only, either due to the presence of scars in the donor flap region, previous pedicle injury, severe obesity, significant comorbidities or patient's desire in procedures that do not require long operative times. We then have as an alternative the reconstruction with expander and implant, which is the technique most used in Portugal. It gives good results, especially when the contralateral breast has small-to-moderate dimensions and no significant ptosis (sagging), and also when a contralateral symmetrisation mammoplasty is programmed. The prerequisite for a satisfactory result is the existence of quality tissues that allow the prosthesis to be covered, which is placed in the submuscular plane. These types of techniques usually require a stay of 1 to 2 days in hospital. The return to professional activity takes about 2-3 weeks, and exertion must be avoided during the first 6 weeks. The results, although generally good, may require a very-long term revision, usually in cases of younger patients who still have a high life expectancy, and in whom complications inherent to the use of prostheses may arise, such as capsular contracture, asymmetry or rupture of the prosthesis.
The reconstruction of the nipple-areola complex is carried out at a later operative time, allowing the determination of the position and final shape of the reconstructed breast after the healing process. The use of autologous tissues in the form of contralateral nipple graft or local flaps ("C-V" flap) and groin skin is our preference, and tattooing is a complement to these surgical techniques. These procedures can be performed in the outpatient setting, and the return to professional activity takes about 2-3 weeks, while physical exertion should only start after 5-6 weeks.
Fat grafting (lipofilling) is a great option for the correction of small deformities and can be performed at the time of breast reconstruction or as an isolated procedure to improve the final result. The fat is harvested from other areas of the body, such as the belly or thighs, prepared and applied to the new breast.
