SUBUCUTANEOUS MASTECTOMY #11

Breast reconstruction may commence at the same time as the original mastectomy, by placing a tissue expander under the thoracic muscles, or later, with a technique that will be selected based on the existing topical condition of the skin in the area.

In order to help the reader understand the technique, which is often not fully understood by breast cancer surgeons, by placing a tissue expander under the muscles during the original surgery, the breast may be reconstructed in just a few weeks with a silicone implant. This process does not hinder the oncological treatment of the patient (chemotherapy or radiotherapy), but simply delays it for a period of a few weeks (6-8 weeks). This is not considered critical for the prognosis of the disease. Placing the silicone implant after the expansion of the skin involves minor surgery. In addition, monitoring topical relapse is not hindered by the implant. On the contrary, breast reconstruction after radiotherapy involves more major techniques, including transfer of perfused tissue, which may often hinder the monitoring of any topical relapse.

Breast reconstruction after mastectomy, but prior to radiotherapy, is performed based on the aforementioned technique, i.e. placing a tissue expander to create extra skin and then replacing it with a silicone implant. Therefore, two procedures need to be performed: one to place the expander and another to replace it with a permanent implant, provided the skin has been expanded during weekly visits to the surgeon. Both surgeries are simple and the patient is discharged on the same day.

When patients undergo radiotherapy, the skin loses its elasticity and results in reduced perfusion to the area. Moreover, the surgical incisions heal with great difficulty. So the best procedure in this case is the transfer of perfused tissue. The most common and preferable flap used in the transverse rectus abdominis myocutaneous (TRAM) flap, from the lower part of the abdomen. This technique renders excellent results in breast reconstruction, as the texture of the skin is compatible to the breast, while at the same time, an abdominoplasty is also performed, which is necessary for most patients. The surgery is major and requires hospitalization of the patient for a few days. The transfer of the flap (i.e. the part of the skin and fat from the lower abdomen) may be performed using the rectus abdominis muscle, while our team more often uses a free flap through microsurgery techniques. This technique may also reconstruct both breasts in case of bilateral mastectomy. The second most popular flap is the latissimus dorsi muscle flap, which, however, also requires the use of a silicone implant. The disadvantage of this flap is that it involves modifying the back angle of the arm pit, which this muscle supports.

Over the last few years, the oncological treatment of many patients has been modified and partial mastectomy techniques are winning ground. Often, a breast tumor may be removed carefully, without removing large parts of the breast, and the patient then receives pharmacological treatment and radiotherapies. Nowadays, this type of breast reconstruction involves stem-cell-enriched fat transplantations.