Breast conservation or breast reconstruction?

The aim of every breast cancer treatment is the complete removal of the tumour. Thanks to a better understanding of tumour biology, it is now possible to perform breast-conserving surgery in the majority of cases. Nevertheless, complete removal of the breast is unavoidable in around a third of all patients. In these cases, a range of reconstruction techniques (immediate or retrospective) are available to those affected. Thanks to the possibilities offered by onco-plastic surgery, holistic treatment concepts are now available that optimally combine tumour removal (oncological side) and breast reconstruction (aesthetic side).

Thanks to a better understanding of tumour biology, the balance in the treatment of breast cancerhas shifted more andmore in favour of breast-preserving therapies. Nevertheless, a mastectomy is unavoidable in around a third of all patients. Of these, however, only a small proportion opt for immediate breast reconstruction. This is despite the fact that such an operation can have a positive effect on the quality of life of the woman affected and has no disadvantage in terms of the chances of curing the cancer. The prognosis is no better if the breast is reconstructed years later.

Immediate reconstruction or later reconstruction?

In recent years, there have been significant developments in reconstruction options, so that the procedures lead to better aesthetic results. It is important to have a comprehensive consultation where different techniques are evaluated based on lifestyle, oncological needs and anatomy. Breast reconstruction can be performed immediately, i.e. at the time of mastectomy, or months or years later. Thanks to improved radiotherapy, chemotherapy and reconstruction methods, immediate reconstruction can now be offered more and more frequently. If immediate breast reconstruction is desired, a skin-sparing mastectomy can be performed. The advantage here is that the mammary gland tissue is only removed via a small incision around the nipple, but the entire skin can be retained. For many patients, however, the question of breast reconstruction only arises at a later stage because they explicitly request it or because they had no knowledge of the possibilities of onco-plastic surgery at the time of their illness. For some patients, the desire for breast reconstruction only grows over time. Breast reconstruction is of course also possible at a later date. It is important that a plan is drawn up before the first treatment begins, which takes into account both medical aspects and fears regarding possible mutilation. This is the only way to ensure that oncological treatment is carried out without compromising quality of life.

Various options for reconstruction

Developments in breast reconstruction are now so advanced that several types of breast reconstruction are possible for every woman. An attempt is made to take individual wishes into account. There are basically three types of breast reconstruction:

1. With a silicone implant;
2. Implant combined with autologous tissue from the back;
3. only autologous tissue from the abdomen, thigh or buttocks
   
   

Reconstruction using implants and expanders

Today we can choose from a very wide range of sizes and shapes of implants of the highest quality, so that the result of a breast that is as natural as possible is realistic even with a foreign body. This surgical technique often requires the tissue and in particular the pectoral muscle to be stretched beforehand. As with secondary reconstruction, the so-called expander is suitable for this. In this procedure, an expander is inserted through the existing scar between the ribs and pectoral muscle. The expander is an empty, fillable silicone cushion. It is gradually filled up so that the skin is stretched, which can take several months. In a second procedure, the expander is then replaced with the silicone implant.

Reconstruction with implant and tissue matrix

The so-called tissue matrix is used in a primary reconstruction. This is a relatively new procedure that serves to strengthen the soft tissue. In certain cases, pre-stretching using an expander can be dispensed with and the definitive implant, combined with the tissue matrix made from pig skin, can be inserted directly. The matrix is fixed to the pectoral muscles on the one hand and to the inframammary fold on the other. In this way, implant reconstruction with very good aesthetic results can be achieved in a one-sided procedure. Initial studies also show that the risk of capsular fibrosis can be significantly reduced.

Reconstruction with back muscle and implant

This procedure is used if the soft tissue in the breast region is very sparse or if radiotherapy has already been carried out. In this reconstruction technique, a piece of tissue with a blood supply (flat muscle with skin islands) is transferred from the back to the breast region by first detaching it from the base and then turning it from the back to the front. The tissue is used to reconstruct the new breast. Depending on the size of the healthy breast, an additional implant must be inserted in order to achieve the same volume as on the opposite side.

Reconstruction with autologous tissue

Most progress has been made in reconstruction techniques using the patient's own tissue, where no muscle is used, only fat reserves. These can be taken from the abdomen, buttocks or thigh. The tissue is transferred to the chest wall and reconnected to new blood vessels using microsurgical techniques. These procedures can be used both in immediate reconstruction and in later reconstruction. The main advantage of this method is that it gives a natural result without the use of implants, but an additional scar must be accepted. Unfortunately, even thanks to the latest techniques and promising methods, it is not always possible to achieve an identical breast in the reconstruction that corresponds exactly to the previous breast. Differences in shape and size are often to be expected. In this case, symmetrising surgery on the healthy, unaffected side may be necessary following the reconstruction. These range from a breast lift to breast reduction and augmentation.

Nipple reconstruction

Nipple reconstruction is the final step in completing breast reconstruction. Nipple reconstruction can only be planned once the breast shape has been restored and any necessary symmetrising corrective procedures have been carried out. However, not every patient considers this part of the reconstruction to be relevant and therefore forgoes it. Nipple and areola reconstruction is performed in different ways. Most commonly, a small skin shift is performed on the reconstructed breast. The areola is reconstructed either by tattooing or skin grafting from the thigh.

Corrective surgery

The result of breast conservation surgery or breast reconstruction does not always meet the patient's expectations. There can be various reasons for this: whether the shape of the breast has changed over the years, severe capsular fibrosis has occurred or too much tissue had to be removed during breast conservation therapy. Nowadays, there are a number of correction options for all of these problems.

Changing the prosthesis for capsular fibrosis

The insertion of an implant leads to a foreign body reaction with the formation of a thin capsule, which in most cases remains soft. In certain cases, particularly following radiotherapy, capsular fibrosis occurs. This is a hard, connective tissue-like, sometimes painful capsule that is accompanied by severe deformation of the breast. The implant must be replaced and the capsule partially removed.

Replacement of the implant with autologous tissue

In the case of severe, extensive capsular fibrosis and if a change of prosthesis has not led to the desired improvement, it is possible to replace the implant with the patient's own tissue. All methods of autologous tissue reconstruction can be considered here. The great advantage of these techniques is that they lead to a permanent result and no further operations will be necessary.

Corrections with autologous fat injections

Following breast conservation therapy or breast reconstruction, dents, soft tissue defects or severe scarring may occur. In these cases, autologous fat injections have established themselves as a very good method for correcting these localised imperfections. As with liposuction, fatty tissue is removed, processed in a special procedure and then injected back into the desired area. In some cases, this procedure has to be repeated. However, it is a minimally invasive procedure with very high patient satisfaction.

Straight to the goal: for a better quality of life and physical integrity

The aim of every breast cancer treatment is to achieve the desired result directly without detours and with as little effort and complications as possible for the patient. The best possible cancer treatment should always go hand in hand with maintaining quality of life and physical integrity.