Breast reconstruction
Breast reconstruction is the plastic reconstruction of the female breast after operations, often because of breast cancer .
General
Every tenth woman today suffers from a malignant degeneration of the mammary gland tissue in the course of her life. Once affected by this disease, the patient is confronted with two fundamental changes: On the one hand, the disease may threaten life. On the other hand, a significant distortion of the breast and thus the destruction of the female self-image is to be feared.
According to the EUSOMA guidelines, breast cancer treatment should only take place in certified breast centers .
In these certified breast centers, comprehensive treatment of the disease is guaranteed by specialists from various fields.
Breast-conserving therapy (BET)
Around 70 percent of all breast cancers can now be treated in a breast-conserving manner.
Tumor removal (possibly in combination with plastic surgery), sentinel lymph node removal (SLNB = Sentinel Lymph Node (lymph node) -biopsy) and / or axillary dissection (ALND) and radiation therapy
The decision as to whether a BET can be done depends on the volume ratio of the tumor to the breast size, the location and distribution of the tumor, and the type of tumor. Breast-conserving therapy is useful if the breast can be preserved without major aesthetic deficits. Plastic-surgical procedures often offer an ideal combination of high oncological (with regard to cancer) safety with preservation and, in individual cases, also improvement of the original breast shape. In the case of large breast volumes and asymmetries, tumor removal can be combined with plastic-surgical reshaping and volume reductions, possibly also on the opposite side in the sense of an adjustment. The BET is mandatory in combination with a subsequent radiation therapy.
To ensure that the tissue removals required to safely and adequately remove the tumor are carried out, a quick section diagnosis can be performed directly during the operation.
Medical reasons against BET
- An existing pregnancy
- Previous radiation treatments on the affected breast
- Rheumatoid arthritis , lupus erythematosus, and scleroderma
- Unfavorable tumor / breast volume ratio
- multicentric involvement of the breast
Non-medical reasons against BET
- Lack of motivation to maintain the breast
- Impossibility to carry out irradiation consistently
- Fear of radiation
- Fear of the breast that produced the cancer
Volume-replacing and volume-reducing method
In principle, volume-replacing or volume-reducing methods are available for reconstructing the shape of the breast.
As part of the BET
Volume replacement
- with small or normal breast
- Local glandular and glandular-skin flap plasty,
- pedicled skin-muscle-flaps
Volume reduction
- with large breast
- Variations of the reduction sculptures and alignment of the opposite side
After breast removal
Volume replacement
Two-stage reconstruction by inserting a tissue expander with expansion of the skin over several weeks and subsequent exchange for a permanent implant, whereby today mainly cohesive material is used, which prevents it from flowing into the body in the event of a rupture . In the medium to long term, problems caused by capsular contractures in the form of hardening and deformations occur more frequently compared to aesthetic breast enlargements . The aesthetic result is often not optimal because the breast does not have a natural shape.
Autologous tissue reconstruction using tissue-pedicled regional flaps, e.g. B. the latissimus dorsi muscle subcutaneous flap or the transverse lower abdominal flap ( TRAM flap ). These procedures are relatively safe and easy to perform. With the latissimus, however, an additional implant must often be used in order to obtain sufficient volume. Here, the disadvantage of a more complex process is combined with the disadvantage of introducing foreign bodies. The TRAM can be sufficient to restore even medium to large breasts, but the main disadvantage is the weakening of the abdominal wall due to the removal of the tissue and the occasional poor blood flow with healing disorders.
Self-tissue reconstruction through free tissue transplantation with microsurgical vascular connection, e.g. B. the perforating flap of the inferior epigastric artery ( DIEP flap ), an improved variation of the free TRAM flap or the perforating flap of the superior gluteal artery (SGAP flap) and the SIEA flap (superficial inferior epigastric artery) . These procedures are associated with considerable personnel and logistical expenditure and require specialized microsurgical training. A permanent and aesthetic result can be achieved with them, but there is a risk of complete tissue loss in the event of a vascular occlusion of the flap vessels.
Breast reconstructions in practice
In daily practice it has been shown time and again that affected women find it difficult to make a quick decision for or against a suitable reconstruction method for understandable reasons. After all, under the shock of the breast cancer diagnosis, it is important to make a rational and short-term decision for or against breast augmentation. Against this background, the final decision on the specific procedure for the reconstruction is partially postponed, insofar as this appears medically reasonable. In this way, the woman can be given time to deal with the new life situation and to find an individual and adapted solution for the patient with her treating physician. During this time, however, the woman also goes through the very difficult situation of breast loss. In order to avoid this psychological trauma, a primary reconstruction of the breast can be carried out; this procedure should be offered to those affected at the therapy discussion. This involves removing the breast and building it up immediately, e.g. B. by a microsurgical autologous tissue graft. This is the best way to plan the shape of the breast without restricting cancer therapy. In principle, the further cancer therapy must not be impaired by the breast reconstruction. Any radiation treatment that may be required plays a very important role in the selection of the reconstruction method. Irradiated tissue is less well supplied with blood than non-irradiated tissue and also tends to transform into connective tissue. Therefore, a reconstruction of the breast with foreign material (implants) in irradiated tissue is more often burdened with complications. In contrast to this, self-perfused tissue introduced into irradiated tissue can significantly improve the soft tissue situation.
An argument against a primary reconstruction is that patients can be so psychologically stressed by the diagnosis that they cannot recognize the consequences of a reconstruction with their own tissue. Alternatives to autologous tissue reconstruction and their risks cannot be weighed against each other. After all, there is, among other things, the risk that the operation will not bring the desired success or that the self-tissue transplant will die. Then, in addition to the missing breast, the patient also has to complain about a lifting defect at the extraction site that should not be underestimated.
The clinics also do not offer all breast repair procedures using autologous tissue, and not every surgeon has the necessary experience and the same aesthetic sensitivity to achieve a satisfactory result for the patient in question. There is a risk that an unsatisfactory primary reconstruction will additionally traumatize the patient.
In the case of skin-saving mastectomy, a temporary treatment with a silicone implant with purse-string sutures can preserve the advantages of a primary reconstruction. The greatest advantage, however, is that the patient's right to self-determination is guaranteed in a more stable psychological situation.
In many cases, there is no irradiation during an ablation.
Reconstruction (deep inferior epigastric perforator flap)
If a deep inferior epigastric perforator flap is used for plastic-surgical reconstruction, this is also known as a " DIEP flap ".
Individual evidence
- ↑ a b c S. Reefy et al .: Oncological outcome and patient satisfaction with skin-sparing mastectomy and immediate breast reconstruction: a prospective observational study. In: BMC Cancer 2010, 10: 171 doi : 10.1186 / 1471-2407-10-171 ( Open Access , under CC-by-2.0)
- ↑ Archive link ( Memento of the original from May 11, 2013 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice.
- ↑ a b V. Naraynsingh et al .: Immediate breast reconstruction following segmentectomy using a latissimus dorsi 'myoadipose' flap through a single axillary incision: a case series. In: Cases Journal 2, 2009, 8116. PMID 19830050 ( Open Access , under CC-by-3.0 license)
- ↑ A. Berger et al .: Plastic surgery: Mamma, trunk, genitalia. Volume 3 of Modern Plastic Surgery in four volumes , Springer, 2006, pp. 199ff., ISBN 3-540-00143-3 , here online
Source
- Tumor Center Munich, EUSOMA, German Society for Senology and numerous scientific publications
