- Andrii Valentynovych, to whom is reconstruction indicated? And are there cases when it is impossible?
- Reconstruction is the restoration of the mammary gland after its complete removal. But a good reconstruction begins with a proper mastectomy. To effectively restore the mammary gland, it is necessary to preserve certain anatomical formations during a mastectomy, and most importantly, the skin. That is, the doctor must keep the surface of the mammary gland intact, as well as the areola and nipple. It is very important that this does not worsen the oncological results of the surgery, provided that the tumor does not grow into the skin and nipple, and this can be checked both during and after the surgery. Performing a mastectomy while preserving the skin and areola is called a “conservative mastectomy,” and it is these interventions that give the best results in reconstructions. The usual, “classical” mastectomy (when the gland is removed from the skin) is actually an outdated method now, therefore it should be performed only for special indications.
Reconstruction can be simultaneous (when removal and restoration occur simultaneously) or delayed - the mammary gland is removed first, and reconstruction is carried out after the main stage of treatment is over, usually in a year or two. But I want to emphasize that even in this case, when performing a mastectomy, the doctor must always consider the possibility of reconstruction in the future. That is, the maximum preservation of the skin, and, if possible, the preservation of the areola and submarine folds (a place under the base of the chest, a natural bend line under the chest) are important technical elements of the surgery.
Fundamentally, reconstruction is indicated for almost all patients. It is impossible only in two cases: when we are dealing with an aggressive, locally advanced form of cancer that is difficult to treat and has a tendency to progression, and the patient’s categorical unwillingness.
Performing reconstructive operations requires special training and highly qualified surgeon. Therefore, it is very important that the patient who agrees to such an operation be informed of what they must perform, be aware of the potential dangers and be sure to understand that the doctor who is taking surgery can not only perform the operation well, but also eliminate all the complications if they will arise. Therefore, agreeing to the reconstruction of the mammary gland, the most important thing is to fall into the hands of a professional.
- How is volume restored? Are implants harmful? How to choose from many offers?
- There are two strategic approaches in reconstructive operations: the use of artificial and own tissues. The first are well-known implants. Most often (70-80%) reconstructions are performed precisely with their use. These can be temporary implants - the so-called expanders, which are used with insufficient tissue to create a beautiful mammary gland, or when surgery carries an increased risk of complications. The second option is the use of permanent implants, which are installed in the area of the removed breast, creating a volume. The classic version of the surgery is the use of muscles to form the pocket of the implant, but such a surgery is relatively traumatic. At the same time, more integumentary tissues are created around the implant, which provides better blood supply, an opportunity for better healing. Today, new technologies allow the so-called pre-pectoral reconstruction, in which the implant is installed in the area of the removed mammary gland without using muscles, directly under the skin. But such a surgery requires special training of the surgeon, and special equipment, and certain anatomical features of a woman. Therefore, as we see, in each case, one should choose the option that is best suited to a particular patient. Also, implants of various manufacturers differ in shape, surface type, density of the filler gel. Each company has its own separate technical "tricks" that distinguish its products from others. Such a “trick” can be very useful in some situations, and therefore the choice of the implant option depends more on each specific clinical case and the surgeon’s knowledge about the possibility and features of the materials, as well as their availability.
Over the past months, a lot of talk has been going on around implants and oncological diseases. Therefore, I want to clarify: implants do not cause cancer, do not increase the risk of disease progression or the appearance of a new tumor neither in patients with cancer, nor for those who, for other reasons, decided to install them. However, a rare form of implant-associated large-cell anaplastic lymphoma (BIAALCL) has been discovered, which occurs in patients who previously had implants installed. But the likelihood of developing this disease is extremely small: on average, 1 case is recorded per 30,000 implants installed. The cause of this disease has not yet been established; there are several versions. Most often, it occurs 8-10 years after the implant is installed, passes in a mild form in the form of fluid accumulation around the implant and is treated by removing it and the capsule. Very rarely, this disease requires systemic treatment - chemotherapy. Now the implant manufacturing company, whose products were most often associated with the development of this disease, has stopped their production and withdrawn from the market around the world.
Given these data, the question of whether to install an implant or not should be decided by the patient herself together with the doctor, but having received objective and adequate information. And today I do not see an alternative to the use of implants. It is an affordable, effective and reliable tool.
- Is reconstruction possible without implants?
- As I already mentioned, such reconstruction is possible using your own tissues, which are transferred from one part of the body to another. These flaps can be on the so-called "leg" containing a vessel that provides blood supply to the flap. The vessel remains intact. It is also possible to use the so-called free flaps, the vessels of which first intersect in the flap removal zone, and then staple with the vessels in the zone of the “lost area” of the body. With such an operation, the patient receives two in one: a flat stomach and natural breasts from her own tissue. Such operations give a good result, but they are quite complex, require the use of microsurgical equipment, special equipment and appropriate training of the surgeon, significant financial, organizational and technical resources. In Western Europe and the USA, this method is quite common and popular. Insurance companies compensate for the cost of such renovations. But the cost of such a surgery is much higher than reconstruction with implants. In Ukraine, this method is not yet very accessible, although, fortunately, more and more centers are mastering this technique and begin to introduce it into clinical practice with good results.
If the woman’s breast size is small and this suits her, then it’s possible to restore the mammary gland using its own fat cells, which are obtained by liposuction (usually from the thighs and the anterior abdominal wall), they are specially treated and injected into the breast zone or into the defect area. This method is safe, but thanks to it it is quite difficult to achieve a large volume. In addition, it requires many repeated interventions, since it is impossible at one time to introduce a large amount of fat into the area of the removed breast. This is a slow gradual process, but at the same time less traumatic.
- And how to restore the nipples?
- This is one of the final stages of breast reconstruction. Quite often, several interventions are required during breast reconstruction. First, the main surgery is performed, and then, corrective surgeries are carried out for one to two years to improve the result. These include the reconstruction of the nipple and areola. There are three main methods for reconstructing the nipple. The first is restoration with the help of our own tissues, when the nipple is formed in a certain way from the skin of the newly created mammary gland. For reconstruction of the areola, the so-called “scarring” can be used - during the surgery, an incision is made in such a way that a scar forms that simulates the areola. It is also possible to transplant free skin flaps into this area, which also mimic the areola.
The second option is a tattoo that plausibly imitates a nipple. 3D tattoos are becoming more and more popular, and for good reason, because in this case, the operation to restore the nipple does not need to be carried out: thanks to the skilled hands of the master, it is possible to imitate a real nipple quite effectively.
There is also a third option, which in Ukraine, unfortunately, is not yet practiced. This is the use of silicone areola prostheses, which are glued to the reconstructed gland and can last quite a long time - up to a year. Then the fixing procedure is repeated. They are of high quality and effectively imitate a real nipple and areola. Although this is a temporary option, it is the safest.
- Many women (especially young ones) think about breast reconstruction before removal or immediately after. So where is the best place to go: a plastic surgery clinic or a specialized cancer treatment institution?
- There are a lot of plastic surgery clinics today. But reconstructive surgery is a special industry, and patients who have undergone mastectomy are a special category. And they definitely should not do reconstructive operations in a clinic or at a doctor who does not have special training and experience in such interventions. Oncoplastic surgery is a specific industry, and its main feature is that the doctor must determine the likelihood of a successful result in the treatment of cancer, and also correlate all procedures with the treatment and follow-up plan. The decision when and how to carry out the reconstruction depends on it. That is why a reconstructive oncologist surgeon with experience in onco-mammology or a specially trained reconstructive surgeon who works closely with oncologists should be involved in breast restoration.
- What should women who have to undergo a mastectomy know?
- The worst thing for a woman is that breast removal can cause a feeling that she will never again feel full, truly self-confident, or that she is not comfortable in the “new” body. But do not say goodbye to femininity! Breast reconstruction will improve the psycho-emotional state, self-esteem, physical activity, as well as the family and, of course, the woman’s sex life.
After breast reconstruction, with the correct organization of the rehabilitation process, patients, as a rule, recover completely and quickly enough. However, they are not recommended for heavy physical exertion on the area of the upper shoulder girdle, especially if there was a reconstruction using the muscles of the anterior chest wall, the so-called retro-pectoral reconstruction. In hospitals where such operations are performed, there must be a rehabilitologist who for each patient forms an individual recovery plan, selects the exercises and the regimen that will be optimal in each individual clinical case.
Do not be afraid, turn to professionals who have extensive experience in conducting such operations, for example, to us at the LISOD Center for Contemporary Mammology. We have a desire to help and knowledge to do this efficiently and safely. Life is worth enjoying!