BREAST RECONSTRUCTION – RECONSTRUCTION AFTER BREAST CANCER

In the DIEP flap method (DIEP-FLAP), skin and fatty tissue with blood vessels are removed from the lower abdomen to reconstruct the breast.

The incision is made in a transverse oval curve from the pubic bone over the navel. The skin at the level of the removed breast is also opened through an incision. The flap of tissue obtained from the abdomen is then formed into a breast, the blood vessels of the abdominal tissue are ‘connected’ to those of the breast and the sutures are closed.

The advantages:

• In contrast to other methods such as TRAM-FLAP, no muscle tissue is used. Therefore, the abdominal wall is not weakened
• The breast can be shaped flexibly, so even large breasts can be restored and excellent aesthetic results can be expected
• The abdominal wall is tightened at the same time as the operation
• The surgical scar runs across the lower abdomen below the waistband. The scar created in addition to the ablation scar lies in the breast crease 

This technique was the forerunner of DIEP surgery and is only offered in centres that have no experience in the field of microsurgery. There are now only a few reasons for this surgical procedure, but our breast surgeons still master this technique. For the pedicled TRAM flap (TRAM-FLAP), autologous tissue from the abdomen is used for breast reconstruction. However, muscle tissue is always used in this technique. The procedure is performed under the skin without interrupting the blood supply. The surgeon makes the incision transversely above the pubic bone and separates the straight abdominal muscle. A so-called TRAM flap, consisting of skin, muscle and subcutaneous fat tissue, is then ‘pushed’ under the skin upwards towards the breast, where the surgeon moulds it into an aesthetic breast shape.

Unfortunately, this method has numerous disadvantages. For this reason, pedicled TRAM flap surgery is only used in rare exceptional cases of breast reconstruction at the ETHIANUM.

Our back muscles have many important functions. If a latissimus dorsi flap is used for breast reconstruction, the broadest back muscle has an additional task. The latissimus dorsi muscle is moved from the back to the front of the upper body together with the surrounding fatty tissue. To do this, the surgeon opens the back and moves the muscle and fatty tissue forwards.

The nerve that controls the muscle in the back is severed in the process. Otherwise, unwanted twitching in the breast could occur because the nerve continues to send signals to the muscle. The new breast is formed from the fatty tissue, the muscle serves primarily as a carrier for the blood circulation. A scar remains on the back, which can be concealed by the bra.

The advantages:

• The blood supply is not cut off during the procedure
• The original function of the muscle is taken over by other back muscles

If the use of autologous tissue from the back or abdomen is not an option, skin or subcutaneous tissue from the buttocks can be used. The operation is performed in the same way as the DIEP flap method, except that the tissue flap is taken from the buttocks rather than the abdomen. In the so-called S-GAP-FLAP, an oval tissue flap is taken from the upper part of the buttocks, in the I-GAP-FLAP from the lower part.

The advantages:

• The method is also suitable for reconstructing large breasts, as the size of the tissue flap removed can be selected relatively flexibly
• The scar created on the breast in addition to the ablation scar lies in the breast crease

The FCI-FLAP is a flap plasty from the gluteal fold in which only skin and fatty tissue are removed. As the supplying vessel runs underneath the gluteal muscles, there is usually no injury to the muscles. The FCI-FLAP is a good alternative to DIEP flap surgery, especially for slim patients.

The advantages:

• Due to the flap design and the flap position, the result is usually a scar that is less conspicuous and runs exactly in the gluteal fold
• The amount of tissue is sufficient for small and medium-sized breasts

(TUG = transverse upper gracilis myocutaneous flap, TMG = transverse myocutaneous gracilis flap)

This procedure is similar to the DIEP-FLAP or S-GAP-FLAP and I-GAP-FLAP method. However, here the surgeon uses tissue from the thigh to shape the breast. In addition to skin and fatty tissue, a very small muscle is also transplanted (gracilis muscle), the absence of which in the thigh does not result in any noticeable loss of muscle strength. A straight, semi-circular incision is made in the groin crease between the pubic area and the thigh over the inner thigh. The breast is modelled, the opening in the thigh is closed by tightening the skin towards the groin and sutured in the groin crease.

The advantages:

• The removal of tissue results in a tightening of the corresponding thigh; if desired, the other thigh can be adjusted by tightening or liposuction
• The scar on the breast in addition to the ablation scar lies in the breast crease, the scar on the thigh is hidden in the groin crease 

In PAP-FLAP flap surgery, skin and fatty tissue are removed from the inner thigh area. It is not necessary to remove the muscles.

The advantages:

• Scars on the inner thigh usually develop inconspicuously
• The amount of tissue is sufficient for small and medium-sized breasts

To build up the breast, an expander is placed under the skin at breast level. This step can be performed during the ablation procedure. The expander, a small plastic cushion, can be gradually filled with a saline solution from the outside via a valve. The skin stretches very slowly until the desired breast size is achieved and the expander can be replaced by the implant after around six weeks. This operation is very similar to breast augmentation in aesthetic surgery.

The advantages:

• No tissue is removed from elsewhere and there are no further scars on other parts of the body
• Also suitable for very slim women who cannot or do not want to spare tissue from their stomach, back or buttocks
• As the other breast is usually matched to the reconstructed breast, breast augmentation can take place with the breast augmentation using the appropriate implant size

To minimise the risk of capsular fibrosis, which must be taken into account when using implants, breast augmentation with implants can be performed in combination with latissimus dorsi flap surgery or autologous fat. In some cases, an artificial tissue substitute is also used.

• Adjustment of the second breast after approx. six to 12 months after the operation
• Adjustment of the buttocks or thighs depending on where the autologous tissue was removed

By the way: Both breast reconstruction after breast cancer and breast augmentation are usually covered by health insurance. Ask your insurance provider about this option.

If you would like more information on the implants used at the ETHIANUM, you can find it here.

We have also compiled further information on second opinions on the use of implants for you.

A negative effect of breast reconstruction on breast cancer can be medically ruled out. Silicone implants in particular have undergone and continue to undergo extensive studies to rule out this risk. What has been found, however: Especially in cancer therapy, a strong psyche is said to have a positive influence on the development of the disease. This is why reconstructive surgery can play a major role after the disease, as the new body sensation is good for the balance of the soul.

After breast reconstruction – whether with autologous tissue or silicone – reliable diagnostic methods such as sonography, mammography and MRI are available to detect any changes in the breast.

If the diseased breast does not require radiotherapy, the procedure can be started immediately in a single operation – even while the breast is still being removed. If radiotherapy is planned, the reconstruction can be carried out afterwards when the skin has regenerated. However, it is of course also possible to successfully reconstruct the breast years after breast removal.