BREAST RECONSTRUCTION
INTRODUCTION
Breast cancer is one of the fearest diseases in women, being cause of an
important morbimortality. The morbidity, aside from the derived one from the
applied therapy, is psychologic, since mastectomy is considered like any
amputation, altering the body image of the woman. THE WOMEN ARE NOT ACCUSTOMED
TO THE LOST of one of her breasts. This demand of solutions on the part of the
mastectomized women has taken to search of techniques of reconstruction.
TRAM
It consists of using the skin and abdominal fat to reconstruct the
breast. This island of skin and fat lives from an artery that is in the
rectus abdominis muscle. Patients who are good candidates:
TECHNIQUE
The operation consists of taking all the leftover abdominal tissue below
the navel with one of the muscles of the abdomen. The flap is transposed to the
thorax under the abdominal skin. The flap is is molded to create a new breast.
The abdominal wall is reconstructed and the resultan sacr is similar to the
left after an aesthetic abdominoplasy. The patient can get up after 48 hours
and to start a near normal life in one or two weeks.
Three months after the first operation a second one is done to make
minor adjustments on the reconstructed breast and to reconstruct the areola and
the nipple. The contralateral, healthy breast is reduced when necessary to
achieve symmetry.
MAMMARY PROSTHESES
Indicated in those thin patients with small breasts in which the skin of
the zone is of good quality and simmetry is easy to obtain. The results are
good if the volume of the breast is about 300 - 400 cc and there is no ptosis. The placement of
implants does not create oncologic problems. It does not mask recurrences and
it mammographies can be performed without problems.
EXPANSION
Indicated in thin patients with great breasts (of 400 cc), in which they
reject the TRAM, in bilateral cases of mastectomias (in where he is but facil
to obtain simetria), and specially in those patients with extended disease who
wish a reconstructed breast. Poor candidates are those patients with the skin damaged or thin, after
radiation and if there is lost tissue. The technique for the placement of the
expander is similar to the prothesis. The approach is through the old scar of
mastectomy. The pectoral muscle is detached and the expander is placed under
the muscle, at least at the level of the mastectomy scar. The inflation begins
one or two weeks postoperatively. In a second stage, 4 to 6 months after the
first time, the expander is replaced by an anatomical phosthesis.
LATISSIMUS DORSI FLAP
This muscle is located at the back and can be transferred to the thorax
to with an island of skin to reconstruct the breast. This indicated after
radical mastectomies where tissue is needed and the patient is not candidate or
does not want a TRAM flap. The flap is placed to reconstruct the lower aspect
of the breast and under the muscle a expander or a prosthesis is placed. In
this way the inferior margin of the flap becomes the submammary fold. This is
the best way to obtain natural ptosis.
In skin-spanning mastectomies the LD flap can be used to fill the breast
and separate the skin from the implant.
RECONSTRUCTION of AREOLA AND NIPPLE
The donor site is chosen depending on the coloration of the areola and nipple
of the healthy breast. The skin has different tonalities on differents parts of
the body and this defines from where we can obtain the skin more similar to the
existing areola. The nipple can be reconstructed from skin of the reconstructed
breast or sharing the contralateral nipple if this large enough. The areola is
reconstructed with inguinal skin, labia minora (patient of black race) or
posterior aspect of the ear (nordicas). Also it is possible to be tattooed.
This procedure can be carried out with local anesthesia.
Dr. J. Benito Ruiz, 1998-2000