Reconstruction

De nos jours, avec le développement de la chirurgie réparatrice moderne, les problèmes de poitrine, qu’ils soient constitutionnels ou liés au cancer du sein, peuvent être réparés chirurgicalement dans des conditions de sécurité optimales, avec un résultat le plus proche du naturel. Cela concerne tout aussi bien les malformations, que la réparation des séquelles de tumorectomie ou la reconstruction du sein après mammectomie.

Breast reconstruction by latissimus dorsi flap

 

This method relies on the removal of skin and muscle on the side of the chest and back. It creates an additional scar there.

Breast reconstruction by latissimus dorsi flap is indicated when the quality of the skin of the chest does not allow a sole prosthetic gesture, and when the morphology of the thorax, the size and shape of the contralateral breast are suitable.

It is rare that the morphology of the thorax and contralateral breast can dispense with prosthesis and use the flap alone.

In most cases, breast volume is reconstructed by combining a prosthesis to the latissimus dorsi flap.

In practice

This method relies on the removal of skin and muscle on the side of the chest and back. It creates an additional scar there.

Breast reconstruction by latissimus dorsi flap is indicated when the quality of the skin of the chest does not allow a sole prosthetic gesture, and when the morphology of the thorax, the size and shape of the contralateral breast are suitable.

It is rare that the morphology of the thorax and contralateral breast can dispense with prosthesis and use the flap alone.

In most cases, breast volume is reconstructed by combining a prosthesis to the latissimus dorsi flap.

 

Prostheses types:

All implants currently used are made of an envelope, and a filler.

The envelope is always in an elastic silicone and can be smooth or textured. In France, authorized fillers are saline and silicone gel.

Implants may be pre-filled with silicone gel or saline by the manufacturer. Inflatable implants are filled with saline by the surgeon during surgery.

 

Elastic silicone envelope

Whether smooth or textured, the exceptional strength of the silicone casing prevents perspiration of the filler through the membrane, as well as wear and risk of rupture. The smooth wall limits the occurrence of folds and waves on the skin, unlike the textured wall that create a “Velcro” effect. However, it would present less risk of postoperative displacement and less capsular pathology.

Only textured implants can be used in breast reconstruction.

 

Filler

Prosthesis prefilled with silicone gel

Silicone gel is a jelly-like substance the use of which prevents the appearance of wrinkles and eliminates the risk of deflation. This substance is not absorbed by the body. All gels used today are called cohesive. That means they do not spread in the body in case of implant rupture.

These gels have the advantage of having a consistency similar to that of a normal breast.

However they may be more or less flexible. The more cohesive they are, the firmer consistency they have.
Today, manufacturers of breast implants offer different types of silicone gel.

Manufacturers typically offer two types of gel :

  • Soft: the prosthesis is very flexible and discreetly changes shape depending on the position of the patient. Unfortunately, these implants can not suit all patients. In general, they are employed under the flaps of latissimus dorsi.
  • Ferm: the breast prosthesis is firmer and slightly changes shape depending on the position of the patient. It is used when the cutaneous tissue is weak to prevent wrinkles and waves in the periphery of the implant, and when the prosthesis is necessary to define the shape of the breast.
  • Today all pre-filled implants available in France are subject to rigorous and precise standards: CE (European Community) + authorization of the AFSSAPS (French agency for food safety of health products).

Saline filled implants during surgery

The saline fluid is a substance composed of water and salt, the concentration of which is close to that of the body. Thus, in case of rupture of the envelope, there is a natural absorption of the solution by the body. The presence of a valve exposes to the risk of sudden and early deflation. There is often a gradual phenomenon of deflation, showing the folds of the skin.

 

Shape

Round prostheses

This round shaped implant has the advantage of offering a more important bulge in the neckline. They do not alter the shape of the breast in case of rotation of the implant, the prosthesis is identical at every point of its periphery. Manufacturers now offer a multitude of different types of round implants. That is what is called the profile. Thus there are four types of profiles for breast round implants:

  • Flat profile: the breast prosthesis is not projected and its base is wide.
  • Moderate profile: the most classic breast implant. The base is quite wide and the projection is average.
  • High profile: the breast prosthesis is projected forward, and its base is narrow.
  • Ultra-high profile: The prosthesis is further projected.

Thus, for constant volume, manufacturers typically offer 4 different types of breast implant

Anatomical prostheses

These anatomical prostheses are designed exclusively with textured envelopes to prevent their rotation and require to be pre-filled with very cohésive silicone gel to maintain their shape. This form provides a very natural appearance, firmness and a youthful feel.

This type of prosthesis is primarily used in breast reconstruction after cancer. The prosthesis being not identical at every point of its periphery (teardrop shape), it must be put in place in orientated manner when facing surgery.

There is a risk of secondary breast deformity by rotation of the implant. The great diversity of forms currently available allows individual customization of each case.

enpratique_recons_prothese

 

Intervention

It is performed under general anesthesia and lasts from 3 to 5 hours.

A range of thoracodorsal skin and the latissimus dorsi are collected by horizontal or oblique incision on the same side as the mastectomy. This flap is pivoted from the area lateral and dorsal to the anterior chest area.

The mastectomy scar is opened and the flap is put in place. The flap donor area is sutured. Drains can suck the postoperative flow and reduce the risk of hematoma.

 

SURGERY AFTERMATH

Postoperative pain varies in intensity. It is systematically and prophylactically taken care of, for each patient.

The vitality of the flap (its color, warmth, capillary pulse) is watched regularly. Any intervention can also present complications.

The dressing is renewed in the second postoperative day. The drains are removed between the second and tenth day.

 

Result

The reconstructed breast is soft, more or less voluminous. Over time, it will tend to follow the natural evolution of the contralateral breast. A second or third operative stage will be needed a few months apart to symmetrize the contralateral breast and reconstruct the areola and nipple.

The unilateral withdrawal of latissimus dorsi muscle does not cause significant functional impairment in daily life. A temporary restriction of shoulder mobility may be the subject of physiotherapy.

Physical therapy in all cases is routinely prescribed.

 

D’après les fiches d’information éditées par la SOFCPRE.

diep

Breast reconstruction with DIEP flap

 
The DIEP flap is a new technique that can be offered to patients with stomach quite generous. The excess skin and fat is mobilized at chest level to reconstruct the breast without using prosthesis.

In practice

The DIEP flap is a new technique that can be offered to patients with stomach quite generous. The excess skin and fat is mobilized at chest level to reconstruct the breast without using prosthesis.

This reconstruction is supported by Medicare.

The procedure involves dissecting a zone of horizontal skin and fat taken from the abdominal area with a sub-umbilical artery and vein but without the rectus muscle and fascia transferred to the thorax and kept alive through the reconnection vessels with vessels of the armpit or chest. This method uses microsurgery.

enpratique_diep1

This flap is shaped in the chest to reconstruct a breast that is natural, without any prosthetic, with such volume as it allows the surgeon to dispense with the use of any internal prosthesis. The reconstructed breast will have little sensitivity to touch.

The technique gives the reconstructed breast shape and flexibility that are quite natural since it is made up of the patient’s own tissues. The closure of donor site causes less scar across the width of the abdomen.

The improvement of the outline of the abdomen is often perceived as a pleasure.

No synthetic reinforcement is put in place to strengthen the abdominal wall because the fact of not taking the rectus fascia ans its aponevrosis prevents from the weakening of the wall.

Symmetrization of the other breast and reconstruction of the nipple-areola complex (nipple + areola) are most often realised later when the reconstructed breast volume is stabilized.

Breast reconstruction does not alter the oncological surveillance.

enpratique_diep2

BEFORE SURGERY

It is a delicate procedure in which blood loss can be significant and it requires that the patient is in good condition.

A preoperative assessment is usually conducted as required. The anesthesiologist will be seen in consultation at least one month before surgery and at least 48 hours before surgery.

A preoperative CT scan of the abdominal wall will be prescribed.

Any medicine containing aspirin should be taken within 10 days before the operation.

The thromboembolic risk of this type of reconstruction is quite high and you will be prescribed anti-embolism stockings (prevention of phlebitis) that you will bring before the intervention until you leave hospital.

You are also asked to buy an abdominal girdle clasping on the front, that will hold you starting from the first dressing. It will later be kept on continuously, for 4 to 6 weeks.

Smoking cessation is essential. It is often responsible for the failure of the intervention.

 

INTERVENTION

It is a classic general anesthesia during which you sleep completely.

The operation can last four to seven hours. After surgery, a plaster modelling your belly is put in place.

 

AFTER INTERVENTION

The postoperative period is usually quite painful for a few days, which may require strong painkillers. These painkillers are then relayed by less powerful analgesics prescribed on demand. Swelling (edema) and bruises of the reconstructed breast are possible, as well as on the belly.

The dressings will be made regularly. The girdle (night and day) must be worn for several weeks. At the begining, the discomfort in the abdomen can be important, requiring the patient to stand a little bent.

Hospitalization of at least 8 days is usually required. The output will be conditioned by the success of the intervention (lack of secondary necrosis) and removal of drainage.

You should consider a recovery time of at least four weeks. Some weakness in the abdominal muscles may persist, which can bother an athletic woman, but this loss of strength is very low: less than 30% on the side of the dissected muscle.

Reconstruction by DIEP immediately restores volume and shape allowing the patient to dress normally and even to wear low-necked garments. The final result is not immediately acquired. At the beginning, the breast may appear a bit too rigid.

The appearance of the reconstructed breast will gradually evolve. It takes two to three months for your surgeon to be able to assess the result and especially the symmetry. It is unfortunately impossible to reconstruct a breast perfectly symmetrical to the other.

There will always remain a certain asymmetry of the breasts, whether it concerns:

  • Volume: the base of the breast will never be perfectly identical.
  • Shape: spreading of both breasts may be different.
  • Color: a small difference is often present
  • Palpation: the reconstructed breast is insensitive.

In some patients, the psychic integration of this insensitive volume can be difficult and a period of ambivalence of at least six months is often found. The medical and family environment plays an important rôle in this period when the patient needs to be reassured.

The DIEP flap breast reconstruction surgery is quite heavy, which means risks associated with any such act.

However, the postoperative course is usually pretty simple. Nevertehless, complications can occur.

The major complication is thrombosis of vascular microanastomosed. It leads to necrosis of the flap. Thrombosis requires further surgery to remove the flap. It leads to failure of reconstruction.

 

D’après les fiches d’information éditées par la SOFCPRE.

Breast reconstruction with prosthesis

 

This intervention aims to restore the volume and contours of the breast by the introduction of a prosthesis. This is the simplest technique, not creating additional scar.

This method is only possible if the skin soft, lax and well vascularized. Otherwise, you must associate with the prosthesis latissimus dorsi flap. For this reason, the pre-operative physiotherapy is highly recommended and smoking cessation is essential.

In practice

This intervention aims to restore the volume and contours of the breast by the introduction of a prosthesis.

This is the simplest technique, not creating additional scar.

This method is only possible if the skin soft, lax and well vascularized. For this reason, the pre-operative physiotherapy is highly recommended and smoking cessation is essential. Otherwise, you must associate with the prosthesis a latissimus dorsi flap.

Prostheses types:

All implants currently used are made of an envelope, and a filler.

The envelope is always in an elastic silicone and can be smooth or textured.

In France, authorized fillers are saline and silicone gel. Implants may be pre-filled with silicone gel or saline by the manufacturer. Inflatable implants are filled with saline by the surgeon during surgery.

 

Elastic silicone envelope

Whether smooth or textured, the exceptional strength of the silicone casing prevents perspiration of the filler through the membrane, as well as wear and risk of rupture. The smooth wall limits the occurrence of folds and waves on the skin, unlike the textured wall that create a “Velcro” effect. However, it would present less risk of postoperative displacement and less capsular pathology.

Only textured implants can be used in breast reconstruction.

 

Filler

Prosthesis prefilled with silicone gel

Silicone gel is a jelly-like substance the use of which prevents the appearance of wrinkles and eliminates the risk of deflation. This substance is not absorbed by the body. All gels used today are called cohesive. That means they do not spread in the body in case of implant rupture.

These gels have the advantage of having a consistency similar to that of a normal breast.

However they may be more or less flexible. The more cohesive they are, the firmer consistency they have.

Today, manufacturers of breast implants offer different types of silicone gel. Manufacturers typically offer two types of gel :

  • Soft: the prosthesis is very flexible and discreetly changes shape depending on the position of the patient. Unfortunately, these implants can not suit all patients. In general, they are employed under the flaps of latissimus dorsi.
  • Ferm: the breast prosthesis is firmer and slightly changes shape depending on the position of the patient. It is used when the cutaneous tissue is weak to prevent wrinkles and waves in the periphery of the implant, and when the prosthesis is necessary to define the shape of the breast.
  • Today all pre-filled implants available in France are subject to rigorous and precise standards: CE (European Community) + authorization of the AFSSAPS (French agency for food safety of health products).

Saline filled implants during surgery

The saline fluid is a substance composed of water and salt, the concentration of which is close to that of the body. Thus, in case of rupture of the envelope, there is a natural absorption of the solution by the body. The presence of a valve exposes to the risk of sudden and early deflation. There is often a gradual phenomenon of deflation, showing the folds of the skin.

 

Shape

Round prostheses

This round shaped implant has the advantage of offering a more important bulge in the neckline. They do not alter the shape of the breast in case of rotation of the implant, the prosthesis is identical at every point of its periphery. Manufacturers now offer a multitude of different types of round implants. That is what is called the profile. Thus there are four types of profiles for breast round implants:

  • Flat profile: the breast prosthesis is not projected and its base is wide.
  • Moderate profile: the most classic breast implant. The base is quite wide and the projection is average.
  • High profile: the breast prosthesis is projected forward, and its base is narrow.
  • Ultra-high profile: The prosthesis is further projected.

Thus, for constant volume, manufacturers typically offer 4 different types of breast implant.

Anatomical prostheses

These anatomical prostheses are designed exclusively with textured envelopes to prevent their rotation and require to be pre-filled with very cohésive silicone gel to maintain their shape. This form provides a very natural appearance, firmness and a youthful feel. This type of prosthesis is primarily used in breast reconstruction after cancer. The prosthesis being not identical at every point of its periphery (teardrop shape), it must be put in place in orientated manner when facing surgery. There is a risk of secondary breast deformity by rotation of the implant. The great diversity of forms currently available allows individual customization of each case.

enpratique_recons_prothese

 

Intervention

It is performed under general anesthesia and takes about one to two hours. The mastectomy scar is opened, thereby avoiding an additional scar.

The prosthesis is inserted into a cavity created under the pectoral muscle against the ribs.

 

SURGERY AFTERMATH

Because of the distension of the pectoralis major muscle by the prosthesis, pain can sometimes be important early days. It is systematically supported proactively tailored to you.

Moreover, as with any surgery, there are risks of complications.

The first dressing is usually removed one day after surgery, and replaced by a sports bra without frame, opening the front. Importantly, to prevent the prosthesis from moving upward, you must also wear a contenseur, which is a sort of belt that presses the top of the breasts. Bra and breast contenseur must be purchased before surgery and must be worn day and night for at least a month.

Skin expansion: : In some cases, a temporary prosthesis for tissue expansion to increase the amount of tissue covering (skin, muscle) may be in place before the permanent prosthesis so as to give a more natural appearance to the reconstructed breast.

If the first implementation of a skin expander, the pain is minimal and the bra is not essential. It will be necessary during the second operation.

 

Results

The volume of the reconstructed breast is firm, very mobile and appearance « juvenile ». A second or third time are needed surgery a few months apart to symmetrize the contralateral breast reconstruction and the areola and nipple.

Un deuxième, voire un troisième temps opératoire sont nécessaires à quelques mois d’intervalle pour symétriser le sein controlatéral et reconstruire l’aréole et le mamelon.

 

D’après les fiches d’information éditées par la SOFCPRE.

malformation

Reconstruction of the areola and contralateral breast symmetrisation

 

The contralateral breast symmetrization

Its purpose is to harmonize the volume and shape of both breasts. It is performed several months after volume reconstruction to give the reconstructed breast time to take its natural place.

This intervention is supported by health insurance after an advance informed agreement procedure.

 

Reconstruction of the areola and nipple

Reconstruction of the areola and nipple is performed either during the operation of symmetrization of the contralateral breast, or a few months after this, but it is really necessary to give the reconstruction a breast appearance.

 

Lipofilling

In some cases, a lipomodelling (lipofilling) may be necessary to harmonize the reconstruction, especially at the neckline.

The reinjection of autologous fat (lipofilling or lipostructure) consists in hidding the implant with taken from the patient herself.

In this indication of reconstructive surgery, lipostructure can be supported by health insurance under certain conditions

In practice

The contralateral breast symmetrization

Its purpose is to harmonize the volume and shape of both breasts. It is performed several months after volume reconstruction to give the reconstructed breast time to take its natural place.

  • If the remaining breast volume is still higher than that of the reconstructed breast and / or falls more, it is reduced and recovered by conventional techniques of mammaplasty reduction or breast ptosis cure
  • On the contrary, if the volume of the reconstructed breast is larger than the remaining breast, the establishment of another prosthesis can be considered in the remaining breast.

This intervention is supported by health insurance after an advance informed agreement procedure.

 

Reconstruction of the areola and nipple

Reconstruction of the areola and nipple is performed either during the operation of symmetrization of the contralateral breast, or a few months after this, but it is really necessary to give the reconstruction a breast appearance.

The areola can be rebuilt with a total skin graft taken from the inner surface of the upper thigh, where the color is darker. The sampling site of the graft is sutured. At the reconstructed areola level, dressings are needed for 3 weeks. Le site de prélèvement de la greffe est suturé. Au niveau de l’aréole reconstruite, des pansements sont nécessaires pendant 3 semaines.

A tattoo can also be performed alone or in addition to eventual transplantation.

The nipple is reconstructed by plastic surgery (local flap) from the skin of the breast, or else, when large, by grafting a portion of the contralateral nipple.

In all cases, the nipple and areola are reconstructed at least 3 months after the reconstruction of the breast volume, so as to have the best possible result.

 

Lipofilling

In some cases, a lipomodelling (lipofilling) may be necessary to harmonize the reconstruction, especially at the neckline.

The reinjection of autologous fat (lipofilling or lipostructure) consists in hidding the implant with taken from the patient herself.

This is a real graft of fat cells.

In this indication of reconstructive surgery, lipostructure can be supported by health insurance under certain conditions.

 

BEFORE INTERVENTION

2 surgery consultations are required before any act of plastic surgery.

An anesthesia consultation is required several days before surgery.

Medical photographs are always made.

Provide for a period of professional unavailability after the procedure, because no sick leave may be prescribed. Depending on circumstances, this period varies from 10 to 15 days. The most important médical instructions are the following ones: stop taking aspirin, anti-inflammatory drugs, or oral anticoagulants within 15 days before the surgery, to reduce the risk of bleeding.

Smoking before and after the intervention is strictly forbidden in order to improve healing.

 

INTERVENTION

You are hospitalized the day before the procedure.

You must be fasting (including water and tobacco).

The procedure is performed under general anesthesia and lasts from 1 to 2 hours.

 

AFTER INTERVENTION

Surveillance takes place in the recovery room first, then in your room.

The hospitalization lasts two days.

Allow a person to accompany you when you return home.

In case of intervention in the breast, a bra will be prescribed before surgery. A girdle will be prescribed before surgery. This girdle is required to compress lipoaspirate areas for taking fat.

The first shower is allowed the day after surgery.

Variably, the days following a lipofilling, there may be present:

  • A swelling that disappears within the first 2 weeks.
  • Bruises, often asymmetric for ten days.
  • A feeling of uncomfortable tension.

There is very rarely pain, which is then relieved by simple analgesics.

Any intervention may also carry risks of complications.

In some cases, localized imperfections can be observed (not that they are real complications): localized undercorrection, mild asymmetry, irregularity.

Control consultations are planned after surgery.

After two to three months, there may be a good idea of the final result.
You should know that, in the future, re-injected fat -injected that took grafting is weight change sensitive. Thus, weight loss entails a volume decrease of lipostructure, whereas weight gain entails a volume increase of lipostructure.

 

D’après les fiches d’information éditées par la SOFCPRE

Poland syndrome and tuberous breasts

 

Tuberous breasts

This abnormality can be classified into three stages which imply different surgical methods.

The abnormality common to all the tuberous breast is an anomaly from the breast implantation base: it takes the aspect of a tuber.

 

Poland’s syndrome

The Poland syndrome combines breast hypoplasia and thoracic deformity of varying importance and sometimes abnormalities of the upper limb. .

In practice

Breast deformities consist mainly of the Poland syndrome and tuberous breasts.

 

TUBEROUS BREASTS

This abnormality can be classified into three stages which imply different surgical methods.

The abnormality common to all the tuberous breast is an anomaly from the breast implantation base: it takes the aspect of a tuber.

The other criteria of tuberous breasts are:

  • A high position of the inframammary fold, constant
  • Abnormalities of the nipple-areola complex: this is always large compared to the volume of the breast.
  • Abnormalities of breast volume. The breasts are usually extremely small but can be normal in size and sometimes hypertrophic.
  • Breast asymmetry is present in more than two thirds of cases. Both breasts are usually tuberous and all grades can be combined.

Treatment:
Treatment will aim to get a chest the most natural and symmetrical possible. For this, it may be necessary to perform on the affected side mammaplasty or develop a prosthesis.

As during breast reconstruction after cancer, symmetrization may subsequently be required.

 

POLAND’S SYNDROME

The Poland syndrome combines breast hypoplasia and thoracic deformity of varying importance and sometimes abnormalities of the upper limb.

The minimal expression of the thoracic deformity is the absence of sternocostal portion of the pectoralis major.

The mammary gland is usually hypoplastic, sometimes completely absent.

The nipple-areola complex is usually small in diameter, located above and outside and can even be completely absent.

Treatment:
In mild forms, the implantation of a breast prosthesis can be associated with a subclavian prosthesis or a lipofilling or a transposition of the latissimus dorsi.

The treatment of major forms of Poland’s syndrome is difficult and is a matter for techniques from breast reconstruction after cancer.

 

D’après les fiches d’information éditées par la SOFCPRE.