Breast Reconstruction

Breast reconstruction has undergone extraordinary advancements in recent decades. New techniques allow for increasingly natural results with less invasive procedures. Breast reconstruction remains an optional procedure, depending on the patient’s choice. There is no urgent need for reconstruction.

There are 2 types of breast reconstruction, depending on when they are performed:

• Delayed from the mastectomy: this is known as secondary breast reconstruction.
• At the same time as the mastectomy: this is known as immediate breast reconstruction.

Secondary breast reconstruction, also known as “delayed breast reconstruction” is the most common scenario. This procedure is offered to patients who have undergone mastectomy but either could not or chose not to undergo immediate reconstruction. It involves “rebuilding” a breast after some time has passed since its removal.

It can be performed in the months following mastectomy or much later, depending on the patient’s choice and any post-operative treatments received (such as radiation therapy, chemotherapy, etc.).

This surgical procedure offers several advantages, the primary one being the ability to focus fully on your initial treatment. Opting for delayed reconstruction also helps the patient come to terms with the loss of the breast, thereby facilitating acceptance of the reconstructed breast.

It’s important to note that each patient is unique and requires an individually tailored reconstruction approach. During your consultation, the surgeon will discuss the most suitable techniques for your specific situation.

Immediate breast reconstruction surgery is performed concurrently with mastectomy, and this more modern technique is suitable for the majority of patients. Immediate breast reconstruction can be achieved using a prosthesis, tissue expander, flap technique, or even fat grafting. It allows the patient to preserve breast volume and achieve reconstruction immediately after mastectomy.

In some cases, such as patients with genetic mutations (BRCA1, BRCA2, …) or tumors located away from the nipple-areola complex, a mastectomy with nipple-areola preservation and immediate breast reconstruction may be feasible. Preserving the nipple-areola complex enhances the aesthetic outcome of breast reconstruction.

This breast surgical procedure offers numerous advantages, the primary one being the avoidance of the sensation of losing a breast. The procedure is typically performed either by the surgeon conducting the mastectomy or jointly by a second surgeon during the same operation.

However, it’s important to discuss the indication for immediate reconstruction prior to breast surgery treatment to assess the benefits and risks for the patient effectively.

Partial breast reconstruction aims to correct and harmonize breast shape. This procedure is often recommended following an operation such as lumpectomy as part of breast cancer treatment or due to an accident.

Partial reconstruction is feasible when breast volume is reduced without significant alteration of its shape or in cases of partial breast deformation with nipple-areola complex retraction.

There are three techniques available for partial breast reconstruction:

• Lipofilling (autologous fat transfer from the patient),
• Breast reduction (for the unaffected breast),
• Flap reconstruction (using tissues from the latissimus dorsi, skin, or abdomen to reconstruct the breast and restore its shape).

It’s important to note that partial breast reconstruction may not be suitable for everyone. During a preliminary consultation, Dr. Sarfati will present the various solutions available based on your specific needs and morphology.

Latissimus Dorsi Flap Breast Reconstruction

Latissimus dorsi flap breast reconstruction involves harvesting skin and muscle from the back (latissimus dorsi) and transferring it forward to reconstruct the breast.

Breast Reconstruction with Implant

Breast reconstruction with implants is the most commonly used technique. It involves placing a breast implant under the skin and generally under the pectoral muscle to recreate breast volume.

DIEP Flap Breast Reconstruction

DIEP flap breast reconstruction is a technique that uses a patient’s own tissue from the abdominal area to reconstruct the breast.

Breast Reconstruction: Nipple and Areola Reconstruction

Nipple and areola reconstruction completes the breast reconstruction process after mastectomy and is typically performed as a secondary procedure.

Breast Reconstruction with Fat Injection

Fat injection (or lipofilling) has revolutionized breast reconstruction. It can be used alone or as a complement to a breast implant.

• Breast Reconstructions with Implants

Breast reconstructions with implants involve the use of a foreign body, resulting in a less natural appearance and requiring future replacement of the implant (typically every 10 to 15 years).

• Autologous Breast Reconstructions

Autologous breast reconstructions are performed using only the patient’s own tissues (flap breast reconstruction, fat injection, etc.). The results are much more natural and stable over time, but they do require an additional scar on the body (except for exclusive fat injection breast reconstruction).

After breast reconstruction, regular follow-up is essential. Firstly, for breast cancer, a consultation and clinical examination are required at least once a year. The schedule is determined by your doctor based on tumor characteristics and treatments received.

For reconstructions with implants, an annual clinical examination is recommended to check the integrity of the implants. Ultrasound or MRI may be recommended if there are any concerns. Breast implants are not permanent; they will need to be replaced in a few years. Predicting the lifespan of an implant is possible, but the idea of systematic replacement every 10 years is entirely false, despite its frequent mention. Implants are replaced when there are issues such as implant leakage, capsular contracture, or implant rotation.

This subsequent surgery is often an opportunity to enhance the aesthetic outcome of the reconstruction and may involve additional procedures such as fat grafting or symmetry adjustments for the other breast.

For autologous reconstructions, a simple clinical examination is required. Occasionally, especially after weight loss, there may be a need for additional fat injections several years later to restore volume to the reconstruction.

Mastectomy after Breast Cancer

Mastectomy involves the removal of the entire breast, including the breast tissue, areola, nipple, and a portion of the breast skin. During this procedure, the major pectoral muscle is typically preserved unless the tumor adheres to the muscle in rare cases.

This intervention is performed in cases of tumor or cancer, or as a complement to conservative surgery.

Breast reconstruction after mastectomy depends on the treatment plan and whether radiotherapy is indicated. If no additional treatment beyond breast removal is recommended, breast reconstruction surgery is an option. However, if additional therapy is necessary, delayed reconstruction is preferred to allow completion of the treatment. Note that a minimum delay of 6 months after radiotherapy is required.

Tumorectomy after Breast Cancer

Tumorectomy is a conservative surgery involving the removal of part of the affected breast in cases of malignant or benign tumors. The goal is to remove the entire lesion with a margin of surrounding tissue.

Tumorectomy is recommended for a single malignant tumor not occupying a significant volume in the breast, lesions at risk of breast cancer, or tumor regression after initial chemotherapy or hormone therapy.

Advancements in oncoplastic techniques now allow simultaneous tumor removal and breast reshaping. However, in some cases, tumorectomy may leave residual effects such as breast deformity or asymmetry. Partial reconstruction is then recommended as a viable solution.

The primary goal of breast reconstruction (beyond the treatment of breast cancer) is to restore confidence in women who have undergone trauma. The operation is a way of restoring a piece of their femininity, a piece of themselves lost through illness or accident. While this decision requires careful consideration, the results attest to its effectiveness.

Dr. Benjamin Sarfati specializes in breast reconstruction. He heads the University Diploma in Oncoplasty and Breast Reconstruction at the University Paris XI. He is also the founder of the first international congress in France exclusively dedicated to reconstructive, aesthetic, and oncological breast surgery: the “Paris Breast Rendez-Vous” (www.parisbreastrendezvous.com). Dr. Sarfati is frequently invited as a speaker at national and international congresses. Always at the forefront of innovation to enhance patient care, he pioneered a world-first: robotic-assisted mastectomy with Da Vinci Xi and immediate breast reconstruction with implants. Dr. Benjamin Sarfati has also contributed to scientific articles and books on breast cancer surgery and breast reconstruction surgery.