Reconstructive plastic surgery

Breast reconstructive surgery

Breast asymmetry

The asymmetry of the breasts is a fairly common condition, as it is nearly impossible to find breasts of identical size and shape in nature. As long as the degree of asymmetry is modest, typically, the condition does not pose a problem. However, it becomes difficult to accept when the asymmetry is pronounced.

The causes

In some cases, it involves congenital causes, meaning there is an altered development of one breast compared to the other. In certain instances, there may be concurrent involvement of the ribcage and pectoral muscle, as seen in cases of Poland Syndrome.

In other cases, it is the result of metasurgical outcomes, meaning consequences due to previous interventions (such as a quadrantectomy or mastectomy). In some instances, the breast develops abnormally due to external factors, such as when wearing an orthopedic brace during adolescence.

What should be done?

While achieving perfect symmetry is very difficult, surgery can provide a solution to the problem by addressing either one breast or both. This may involve increasing volume where deficient or decreasing it if excessive, lifting or lowering the breast fold, reducing the areola if overly large, and modifying its shape through simple glandular reshaping or, if necessary, through the introduction of an implant or adipose tissue transplant. Each case requires careful and reasoned evaluation.

Reconstruction after oncologic surgery

The reconstructive surgical techniques for the breast after demolitive oncologic interventions are diverse. The choice depends on various factors such as the characteristics of the performed procedure, the patient’s age, overall health conditions, skin quality, and the shape and volume of the contralateral breast. Nowadays, reconstruction is almost always performed or at least planned concurrently with the demolitive procedure (oncoplastic surgery) through collaboration between the general surgeon and the plastic surgeon, or because the plastic surgeon is capable of addressing both issues.

Immediate reconstruction: Oncoplastic surgery

Breast oncoplastic surgery is the new frontier in the surgical treatment of breast tumors. The principles underlying oncoplastic surgery are those of oncological appropriateness and adequacy of treatment (radicality criteria) in conjunction with the principle of respecting tissues and shapes. The guiding principles of oncoplastic surgery place the patient in the best conditions for performing an immediate reconstructive intervention. Modern techniques often allow for the advanced reconstruction of the breast to be associated with the demolitive procedure, reducing the need for subsequent interventions. In particular: CONTEXTUAL RECONSTRUCTION OF QUADRANTECTOMY: This involves removing portions of the breast along incision lines that allow for the reconstruction of the breast cone. For example: A lower quadrantectomy can be performed following the pattern of an aesthetic mastopexy, leaving a vertical and periareolar scar of excellent quality, instead of the conventional removal of the diamond-shaped area of skin and breast, which can lead to a disfiguring result. Contextual symmetrization of the breasts (e.g., by removing a quadrant on one side and modeling the contralateral side with a slight reduction in volume). Secondary reconstruction of quadrantectomies, if performed later, is often challenging due to the radiation therapy that is frequently required.
CONTEXTUAL RECONSTRUCTION OF ONE-STAGE MASTECTOMY: There are techniques today that allow for the reconstruction of the breast in a single stage (e.g., the so-called Skin Sparing and Skin Reducing techniques) through the immediate placement of definitive implants.
TWO-STAGE RECONSTRUCTION OF MASTECTOMY: In some cases, two-stage reconstruction is still the most appropriate. The method involves placing an expander. Skin expanders are widely used in both immediate and delayed reconstruction. Their use allows, although requiring two surgeries, for a more natural shape to be given to the reconstructed breast. The expander is placed under the large pectoral muscle and under the midline of the serratus anterior muscle, another chest muscle. The expander has a tube connected to a small plate that is positioned under the skin in an easily accessible area. Over the months following the first surgery, the expander can be gradually inflated through the plate until the desired volume is reached. In the second surgery, the expander is removed and replaced with the definitive prosthesis.
SUBCUTANEOUS MASTECTOMY AND CONTEXTUAL RECONSTRUCTION: Subcutaneous mastectomy involves removing the entire mammary gland while preserving the overlying skin. In these cases, immediate reconstruction is carried out since, if the removed volume is not quickly replaced, scar retraction makes reconstruction difficult in a later stage. The prosthesis is placed beneath the chest muscles (mainly the pectoralis major muscle). Either definitive or expandable prostheses can be used. In many cases, a second intervention is necessary to shape and readjust the breast on the opposite side, where a breast reduction or mastopexy (breast lift) is performed.

Deferred breast reconstruction

Delayed breast reconstruction should be scheduled at least 4-6 months after the mastectomy to allow for dealing with soft and “healed” tissues. Reconstruction can be accomplished through:

  1. Autologous tissue, i.e., the patient’s own tissue (Flaps).
  2. Skin expanders and/or implants if the pectoral muscle is preserved, and the overlying skin is sufficient to cover a breast cone. Reconstruction with only the insertion of a definitive breast implant is possible. However, more commonly, skin expanders are inserted.
  3. Combination of flaps and implants.

Reconstruction with flaps

This flap is used when there is not a sufficient amount of good-quality skin to cover a breast implant. The flap, which includes the muscle fascia, is designed starting from the inframammary fold and extended laterally. It is transferred by rotating it approximately 90° to fill the scarred area. The implant is then positioned beneath the muscle plane as usual. This technique allows for a one-stage breast reconstruction without the need for expansion. The resulting scars are broader but largely confined to the bra cup area.
– Latissimus Dorsi Musculocutaneous Flap:

This flap is used in situations where both skin and muscle need to be replaced, potentially replacing the atrophic or even absent pectoralis major muscle due to radiation treatments or more radical mastectomies. Usually, the volume needs to be supplemented with an implant. The latissimus dorsi flap is a viable alternative to reconstruction with the rectus abdominis muscle, although it is more suitable for reconstructing less voluminous breasts or addressing significant deficits from quadrantectomies.
– Rectus Abdominis Musculocutaneous Flap (TRAM Flap):

This technique allows for the reconstruction of a significant breast volume and adjustment to a ptotic (drooping) and voluminous contralateral breast. It involves transferring a large area of skin and adipose tissue from the lower abdomen, below the navel, to the breast region. Modern techniques aim to spare muscle tissue and reduce the risk of secondary complications such as abdominal hernias through minimally invasive techniques and microsurgery.

Contralateral symmetrization

Breast reconstruction, excluding the technique with the musculocutaneous flap of the rectus abdominis muscle, leads to a conical and non-ptotic breast. Consequently, it is often necessary to intervene on the contralateral breast (on the opposite side) in the following ways:

  1. Correcting the degree of ptosis through balancing mastopexy (breast lift);
  2. Reducing its volume with a proper breast reduction;
  3. Increasing its volume with calibrated additive mastoplasty.

Areola and nipple reconstruction

The reconstructive surgical techniques for the breast following demolitive oncological interventions are varied. The choice depends on various factors such as the characteristics of the procedure performed, the patient’s age, general conditions, skin quality, and the shape and volume of the contralateral breast.

In today’s practice, breast reconstruction is almost always performed or at least planned simultaneously with the demolitive procedure (oncoplastic surgery). This is made possible through collaboration between the general surgeon and the plastic surgeon, or because the plastic surgeon is skilled in addressing both aspects.

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