What Are the Goals of Breast Reconstruction?

Breast reconstruction surgery generally aims to achieve three main goals:

Restoring the volume and shape of the missing breast:
This can be achieved using several techniques, including implants, tissue expanders, inflatable implants, fat injection, fat or muscle-tissue transfer, and flap procedures such as DIEP, TUG, or SGAP.

Achieving symmetry with the opposite breast:
This may be performed when necessary and according to the patient’s wishes.

Reconstructing the nipple and areola:
This may also be performed if desired by the patient.

Stages of Breast Reconstruction

The timing and sequence of reconstruction vary from one patient to another. The process often requires two to three operations, usually separated by at least three months.

A typical reconstruction plan may include:

• Reconstruction of the missing breast.
• Surgery to improve symmetry with the opposite breast.
• Reconstruction of the nipple and areola, with additional refinements if necessary.

Possible Alternative Approach

In some cases, a two-stage strategy may be considered:

• Reconstruction of the missing breast and correction of the opposite breast during the same operation.
• Reconstruction of the nipple and areola, with further adjustments if required.

Immediate Versus Delayed Reconstruction

Breast reconstruction may be performed after chemotherapy and radiotherapy have been completed, which is known as delayed reconstruction.

When medically appropriate, it may also be performed at the same time as the mastectomy, which is known as immediate reconstruction.

Breast Reconstruction Techniques

Implant-Based Reconstruction

Breast reconstruction using an implant is a relatively straightforward procedure and does not usually create an additional donor-site scar. However, this technique can only be used when the skin and soft tissues of the chest are sufficiently flexible and healthy.

A cohesive silicone implant is used to restore breast volume and shape. The procedure usually takes approximately one hour and is performed under general anesthesia.

Discomfort may be more noticeable during the first few days but can usually be managed with pain medication. Hospitalization generally lasts between 24 and 48 hours, and recovery may take approximately two to three weeks.

The reconstructed breast may feel firmer and have less natural movement than a breast reconstructed using the patient’s own tissue.

The main potential complications include:

• Capsular contracture.
• Implant exposure or rejection.
• Implant rupture.
• The possible need for implant replacement.

Breast implants last an average of approximately ten years, although this can vary between patients.

Symmetry with the opposite breast may be achieved during the same procedure or several months later. Nipple and areola reconstruction can then be performed.

In some cases, I may use a composite or hybrid reconstruction technique that combines an implant with fat injection. This can improve the quality and flexibility of the overlying tissues, soften the implant edges, and create a more natural-looking result.

Reconstruction with Fat Transfer (Lipofilling)

Breast reconstruction using fat transfer is a natural technique that uses the patient’s own fat without requiring a synthetic implant.

Fat is removed from areas such as the thighs, abdomen, or hips through liposuction. It is then purified and carefully reinjected into the breast area.

A sufficient amount of donor fat must be available to achieve the desired volume. If the fold beneath the breast is poorly defined, an additional tissue-transfer or reconstructive procedure may be required to recreate the breast contour.

Fat transfer may also be used after partial mastectomy or lumpectomy to correct asymmetry, depressions, or contour irregularities.

Several treatment sessions may be required to achieve the desired volume, with an average of approximately four to seven sessions in some cases.

These procedures are generally less extensive and may involve:

• A short hospital stay or day-case admission.
• Tightness or discomfort in the liposuction areas.
• Wearing a compression garment for approximately one month.
• An average recovery period of around seven days.

However, multiple procedures may be necessary.

Approximately 30% of the transferred fat may be absorbed by the body before the remaining fat stabilizes.

The technique may sometimes be supported by the BRAVA system, an external suction device placed over the breast to help prepare the tissues and support fat-cell survival.

DIEP Flap Reconstruction

DIEP flap reconstruction involves transferring skin and fat from the abdomen to reconstruct the breast.

The tissue is transferred together with its blood vessels, which are reconnected to blood vessels in the chest using microsurgical techniques.

This procedure is combined with an abdominal-contouring effect similar to a tummy tuck. It leaves a scar that is usually concealed beneath underwear, similar to a cesarean-section scar but generally longer.

The procedure requires:

• Sufficient excess skin and fat in the lower abdomen.
• Suitable blood vessels for microsurgical connection.

The surgeon may request imaging studies to confirm that the required blood vessels are available.

The procedure usually takes approximately five hours and may require hospitalization for around one week. The average recovery period is approximately 30 days.

Unlike TRAM flap reconstruction, the abdominal muscles are preserved.

The risk of total flap failure is approximately 3% to 5%.

The final result often looks and feels natural because the reconstructed breast is made using the patient’s own skin and fat.

Reconstruction with Other Flaps

TUG, SGAP, and IGAP flaps:
These techniques use tissue taken from the inner thigh or buttock area.

TRAM flap:
This technique transfers the rectus abdominis muscle together with the surrounding skin and fat. It is an older technique and is now used less frequently because of the development of the DIEP flap.

Latissimus dorsi flap:
This technique uses skin and muscle from the back. It may be considered when the tissues of the chest are not flexible enough to support an implant or when DIEP and other flap procedures are not suitable.

The latissimus dorsi flap may be used:

• On its own.
• Together with an implant.
• In combination with fat transfer.

Achieving Symmetry and Reconstructing the Nipple and Areola

Symmetry

Symmetry may be improved using cosmetic breast surgery techniques, including:

• Breast implants.
• Fat transfer.
• Breast lifting or correction of sagging.

Nipple and Areola Reconstruction

Nipple and areola reconstruction is usually performed during the final stage of treatment. It may involve a minor surgical procedure or other techniques such as medical tattooing.

Reconstruction with Tissue Expanders or Inflatable Implants

In some cases, the skin and soft tissues of the chest may not be flexible enough to accommodate a large permanent implant immediately.

A temporary tissue expander or inflatable implant with a valve may then be used. Saline solution is gradually injected through the valve over several appointments to expand the tissues.

Once the desired volume has been achieved, the temporary expander is replaced with a permanent implant.

Possible Complications

As with any surgical procedure, potential complications may occur, including:

• Infection.
• Bleeding.
• Changes in sensation around the breast or nipple.
• Scarring.
• Implant-related problems such as rupture or deflation.
• Complications associated with autologous tissue transfer, including partial loss of the transferred tissue or flap.

Financial Coverage for Breast Reconstruction

Health insurance may cover a significant portion of the cost of breast reconstruction because it is considered part of breast cancer treatment.

Additional expenses, such as professional or surgeon’s fees, may still apply. These costs may be partially or fully covered by supplementary health insurance, depending on the patient’s insurance policy and coverage.