breast reconstruction

General information about the breast structure

After a mastectomy (mastectomy) many women want to conceal the procedure – ie the absence of one or both breasts. In addition to breast prostheses, there is also a permanent solution: the breast structure (breast reconstruction). In this plastic-reconstructive surgery, the breast and nipple are restored – either with implants or self-tissue. If a unilaterally amputated breast is reconstructed, often the remaining breast has to undergo a smoothing operation – so that the end result is symmetrical.

According to current knowledge, the breast structure seems to have no effect on the course of the disease or the detection of relapses (local recurrences). Surely this can not be said, because appropriate studies are missing.

Breast Build: The right time

In principle, a breast reconstruction can be performed at any time – either in combination with mastectomy (primary reconstruction, one-step procedure) or as a separate procedure at a later time (secondary reconstruction, two-stage procedure). Primary reconstruction (immediately after amputation) is less of a mental burden for some women.

Other patients, on the other hand, first want to recover from mastectomy and calmly deal with the various options of plastic surgery before undergoing breast augmentation. An additional influence on the optimal time for breast augmentation also plays a role in further treatment planning, ie whether, for example, radiation is planned after the amputation.

Brustaufbau: Which procedure?

There are different methods for breast augmentation: on the one hand the reconstruction with implants (mostly silicone implants) and on the other hand different procedures for breast augmentation with own tissue. It can also be combined. Which method is most suitable in an individual case depends not only on the needs and wishes of the woman but also on medical criteria.

These include, for example, the general state of health, the size of the breast, tissue and scarring conditions on the operated breast and further treatment planning. Radiation therapy, for example, severely affects the skin in the chest, which must be taken into account when selecting breast reconstruction procedures.

Breast construction with implants

For breast augmentation with implants, physicians usually use plastic cushions with a silicone gel filling. They are considered safe, although there have been reports in recent years of problems with cheap implants and implants with unauthorized fillers. It is also unclear whether silicone implants trigger diseases such as cancer – in any case, such diseases would be very rare.

There are also implants that are filled with a saline solution. Such implants are usually used only as a temporary solution. Other implants are hardly or not at all used in Germany (aqueous hydrogel implants, breast implants with soybean oil).

So the breast implant is used

The implants are placed under the skin, either above or below the pectoral muscle. In some women, the skin is too tight after the healing of the surgical wound. Then it has to be stretched with an expander before inserting the implant: this refillable plastic bag is placed empty under the skin and subsequently gradually filled with saline solution (via a valve with a hypodermic needle). The skin is stretched so slowly. After a few months, the expander can be removed and the actual implant inserted.

Durability of silicone implants

Modern breast implants are considered safe and long lasting. But some of them do not last a lifetime. Especially if the implant is used in younger women, after a few years an exchange may become necessary. In any case, it is advisable to have the breast implant checked regularly by a doctor. If pain, breast reduction, lumps or bumps in the chest occur, women should go to the doctor. Maybe there is a faulty implant behind it.

Breast construction with implants: advantages and disadvantages

Breast augmentation with implants is a relatively short, simple operation that involves few risks. Compared to a breast reconstruction with own tissue, it usually causes less pain, and there are no additional large scars (such as on the stomach or back by the removal of self-tissue). Wound healing is completed fairly quickly.

Some women need some time to get used to the breast implant. There are also women who report chills in the chest after inserting the implant.

In response to the silicone implants, the body surrounds them with connective tissue. This can lead to indurations that, in the worst case, squeeze the implant, causing pain and deformation of the breast. With such a capsular contracture, the implant is usually replaced.

Radiation therapy can be problematic in breast implants.

Breast construction with own tissue

A breast reconstruction is also possible with own tissue: To do this, the doctor removes a skin-fat flap with or without musculature from another body site and forms the new breast.

Operations with muscles

Often, a TRAM flap (transversus rectus abdominalis flap) is used for self-tissue breast augmentation: A skin-adipose tissue flap is removed transversely on the lower abdomen along with a portion of the rectal abdominal muscle. It can be transplanted into the chest area as a “pedunculated” or “free” flap:

In a “stalked” TRAM rag the supplying vessels are not severed. They must be long enough for the skin-fat tissue-muscle flap to be swung up to the chest.

In a “free” flap, the vessels are severed. After being transplanted into the chest area, the flap must therefore be sutured microsurgically with new blood vessels, so that the tissue is sufficiently supplied.

Alternatively, a skin-adipose tissue-muscle flap is also used by the area of ​​the great back muscle (LADO = musculus latissimus dorsi) or, in exceptional cases, by the thigh (TMG = transverse musculocutanaeus gracilis) for breast augmentation.

Operations without musculature

The DIEP (deep inferior epigastric perforator) rag consists of deep skin and fat tissue from the abdomen, but without muscle. Sometimes a superficial skin and fatty tissue flap is also removed from the abdomen (SIEP = superficial inferior epigastric artery).

Women who are very slim often do not have enough fat on their stomach. Skin and fat tissue from the lower or upper buttock can then be used to build up the breast (I-GAP = inferior gluteal artery perforator).

Breast construction with own tissue: advantages and disadvantages

A breast reconstruction with own tissue usually looks natural and is more durable than the insertion of breast implants. Later corrections are only rarely necessary. In addition, there are no problems with radiotherapy in this type of breast.

On the other hand, the breast structure with intrinsic tissue is more complex and involves more complications than the insertion of implants. Sometimes reoperations are necessary. In addition, the tissue removal leaves larger scars on the relevant body site.

The removal of a tissue flap with muscles (as with the TRAM flap) has the disadvantage that in the removal area movement restrictions, muscle weakness and pain can occur. This is not the case when removing a tissue flap without muscles (as with the DIEP-flap).

However, the latter procedure is more complex and requires a special experience from the surgeon: he has to create a new vascular supply for the tissue flap. In addition, in a breast reconstruction with a tissue flap without muscle the risk of tissue death (necrosis) is greater than with the use of a tissue flap with muscles or implants.

Experimental: Breast build-up with autologous fat

The method to reconstruct an amputated breast only with autologous fat (without skin and muscle) is still being researched. It is rarely used in Germany and mostly in studies. The fat for the breast structure wins the surgeon by suction from the stomach, back or hips. It has to be injected several times into the breast because it is partly broken down by the body.

Reconstruction of the nipple

Once the breast has healed completely after reconstruction (which usually takes several months), the nipple can still be reconstructed. The waiting time is necessary because the reconstructed breast often changes a bit after the procedure. Thus, for example, the skin can yield slightly when implants are inserted, a breast reshaped with self-tissue may lower somewhat.

The reconstruction of the nipple can be done either with its own skin tissue (such as the other nipple or the abdomen) or by tattooing (in a specialized clinic or practice).

The cost of breast augmentation

The cost of common procedures for breast reconstruction after a breast cancer are taken over by statutory health insurance. Private insured persons should discuss the reimbursement in advance with their health fund.