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Surgical Procedure
Surgical breast reconstruction after mastectomy consists of two general types of procedures: those involving expanders or implants, and those using your own tissue flap or the person’s own tissue (Autologous) to replace the loss tissue.
You have the following options to consider when choosing a type of breast reconstruction:
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Temporary tissue expander subsequently replaced for a permanent implant. |
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Permanent tissue expander requiring only valve removal. |
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Latissimus dorsi musculocutaneous flap with implant or expander. |
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Autologous flap of the latissimus dorsi muscle. |
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Autologous flap of the transverse rectus abdominis myocutaneous (TRAM). |
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Free tissue transfer, also called free flap for implant to be attached in the chest. This requires the use of a microscope (microsurgery). |
Since mastectomy involves loss of breast tissue, specifics of the breast reconstruction surgery are unique for each patient. Your surgeon will advise you on the type of breast reconstruction or combination of procedures that are most suitable for you. During the procedure selection your doctor will observe the following aspects:
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Laxity and thickness of the remaining chest skin. |
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Condition of the pectoralis and serratus muscles. |
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Size of the opposite breast. |
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Availability of flap donor sites in other parts of the body. |
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Breast reconstruction procedures
What types of procedures do exist for breast reconstruction?
Esta técnica o conjunto de procedimientos supone la utilización de tejido autógeno, es decir, del mismo paciente y se emplea en aquellas pacientes con insuficiente tejido mamario. Si bien la complejidad que involucra este tipo de tratamiento, amplía el tiempo de permanencia en quirófano, así mismo, las técnicas de colgajos ofrecen al cirujano la ventaja de trabajar con el tejido del propio paciente, que refleja sus mismas características y además se adapta mejor. El volumen de las mamas es calculado preoperatoriamente y el diseño del colgajo se ajusta a la extensión que refleja el área a tratar, posterior a la mastectomía.
1. Tissue flap procedures
This technique uses autologous tissue, which is your own tissue, to replace this in insufficient breast tissue cases. Although tissue flap procedure requires more time in surgery, this procedure provides the advantage of using the same patient´s tissue. This technique rebuilds the breast so that it is about the same size and shape as it was before mastectomy, and the flap size is adapted to the breast reconstruction site.
Pedicled flap
What is a flap? What is a pedicled flap?
A flap is a piece of tissue that is transplanted from one area of the body to another. This flap contains blood vessels, skin, subcutaneous tissue and muscle. In the pedicled flap, tissue is transferred maintaining its original vascular pedicle. The tissue is left attached to the donor site and simply transposed to a new location keeping the “pedicle” intact as a conduit to supply the tissue with blood.
Free flap
In contrast to the pedicled flap, the free flap or free tissue transfer describes the complete movement of tissue from one site on the body to another. Tissue, along with its blood supply, is detached from the donor site and transferred to the recipient site. This requires the use of a microscope (microsurgery) to connect the tiny vessels in the recipient site.
These surgery procedures involve a careful planning, development and transference technique.
Types of breast reconstruction using flaps
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Latissimus dorsi musculocutaneous flap with implant or expander
In The latissimus dorsi breast reconstruction method is a tissue flap procedure in which the surgeon moves muscle and skin from the patient´s upper back or latissimus dorsi muscle to the reconstruction site. An implant may be placed during the procedure or later in another procedure. The advantages with this type of reconstruction procedure are that the flap keeps its original blood supply and also, that this method provides a more natural form to the reconstructed breast. However, patient should understand that this procedure can produce considerable permanent scars on the back and around the new breast. |
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Autologous flap of the transverse rectus abdominis muscle (TRAM)
The autologous flap of the transverse rectus abdominis muscle, also called TRAM flap is a tissue flap procedure that uses muscle, subcutaneous tissue and skin from the abdomen of the patient to create a new breast. The TRAM flap is tunneled under the skin to reach the inframammary fold. However, patient should understand that this procedure can produce considerable permanent scars on the abdomen area and around the new breast. |
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Free tissue transfer<0} or free flap
Free tissue transfer, also called free flap method, has become a frequently used option in breast reconstruction after mastectomy. If performed along with mastectomy, the free flap procedure provides a better blood supply and therefore a lower incidence of necrosis. In a free flap reconstruction, tissue from the abdomen or the buttocks is transferred to the breast area. The tissue is completely removed from the donor site and reconnected to a new blood supply using the microscope. |
2. Breast reconstruction with implants
Breast reconstruction with implants alone depends on the presence of enough soft tissue so a complete coverage of the implant can be obtained. Submuscular implant placement is associated with a lower incidence of capsular contracture in comparison to the subcutaneous implant placement.
3. Breast reconstruction with expanders
What are expanders?
When your doctor talks about expanders, he means a technique that allows the gradual stretching of the chest tissue to create space for placement of a permanent implant later. This surgery method is known as breast reconstruction with tissue expanders and may involve two phases. In a first procedure, an implant tissue expander is placed beneath the major pectoralis muscle and over the Inframammary fold. This method is performed through a transaxillary approach. Once the tissue expander is placed, through a tiny valve the surgeon injects a saline solution. It requires many visits to the surgeon after tissue expander placement to slowly fill the device through the internal valve. The expansion is performed under sterile conditions and the tissue expander is slowly inflated until it reaches the right size. The expander is left in place for approximately two months and a half, or for the time that may be required.
In the second surgical procedure, the expander is removed through the same incision it was inserted through, and the adequate size silicone gel implant is inserted. The aim is to reach as closely as possible the remaining natural breast size.
The nipple-areola complex reconstruction surgery is scheduled a few months later.
What is the expander like?
There are different types of tissue expanders.The most commonly used is the tissue expander with valve, like a balloon, which is equipped with a tiny valve, through which saline can be pumped. The valve allows controlling the expander filling. Hypodermic needles are used to introduce the saline into the expander.
Nipple-areola complex
How is the nipple-areola complex reconstruction done?
Dr. Nieto considers that nipple-areola complex reconstruction enhances the realism of the breast reconstruction. Some patients may only want to have the shape of the breasts. However, the surgeon has the medical commitment to perform the best possible treatment that more closely resembles the natural shape of the breast. Nipple-areola reconstruction is essential for both physical and psychological reasons. Though, it is important patient understands that even in the most skilled hands, the reconstructed breast will never be exactly like the original.
The nipple-areola reconstruction represents the final stage of a complete breast reconstruction. Construction of the nipple-areola complex usually is performed 2-6 months following reconstruction, when the breast has taken its final shape and position.
Surgery techniques for nipple-areola complex reconstruction
What techniques are used in the reconstruction of the nipple-areola complex?
A variety of tissues can be grafted to the breast mound to create a new nipple.
The nipple-areola complex reconstruction techniques depend on the type of tissue used for reconstruction:
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Nipple division of the remaining breast
Nipple reconstruction may involve nipple sharing with the contralateral breast. |
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Labia minora and labia majora tissues
Skin grafts are taken from other parts of the body in order to reconstruct the nipple-areola complex. This reconstructive technique uses grafts from the genital area. Usually, a graft from the labia majora is used to reconstruct the areola and a graft from the labia minora for the nipple. The skin quality from these tissues provides satisfying results in the nipple-areola complex reconstruction. |
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Auricular cartilage
Auricular and post-auricular cartilages are used to reconstruct the nipple-areola complex. |
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Buccal mucosa
When a light pink color of the nipple-areola complex is desired, grafts from the buccal mucosa can be used to reconstruct this area. However, this technique is not frequently used. |
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Areola tattooing
Many women now opt for nipple-areolar reconstruction by tattooing to simulate areolar shadow. The permanent areola repigmentation and nipple restoration technique employs cosmetically tattooed micropigmentation as a way to restore the natural beauty of breasts. This method provides a very satisfactory replication of the areola. |
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Treatment of the contralateral breast
Many patients find that breast reconstruction hardly produces a breast that is symmetrical with the opposite breast. Therefore, alteration of the opposite breast to achieve symmetry may be required. The options for the contralateral breast treatment include the usual surgery techniques for breasts. In those patients at risk of developing breast cancer in the opposite breast, a prophylactic mastectomy with breast implant reconstruction may be considered, with subsequent submuscular implant placement.
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