Reconstruction after mastectomy subcutaneous
Subcutaneous mastectomy involves the removal of the entire mammary gland intact preserving the overlying skin. In these cases we proceed to the immediate reconstruction because, if not rapidly integrates the volume removed, the skin of the cicatricial retraction makes difficult the reconstruction at a later time. The prosthesis is positioned below the chest muscles, particularly the pectoralis major. You can use permanent implants or expandable prosthesis. In many cases it is necessary a second operation to shape and adapt the udder of the opposite side on which you perform a breast reduction or a breast lift.
Breast reconstruction after quadrantectomy
The quadrantectomy consists in the removal of a breast quadrant that includes the portion of the gland affected by the disease and that includes the overlying skin. The remaining breast is then subjected to radiation therapy. Normally the leaves quadrantectomy good results from an aesthetic point of view. However, there are situations (15 -20%) where the outcomes are unfavorable. Correct these situations after the radiation treatment presents many difficulties for the limited tropism and elasticity of the irradiated tissues. The optimal situation is the immediate correction. Depending on the deformity can be adopted various measures: Remodeling of the breast cone; volumetric integration (prostheses and / or flap); Integration skin (skin flap or skin + muscle); Remodeling of the breast of the opposite side.
Total post-mastectomy reconstruction
The radical mastectomy involves the removal of the entire breast including the skin and in the removal of the pectoral muscles (m. Radical sec. Halsted) or saving the pectoralis major muscle (m.radicale modified). The reconstruction can be accomplished according to three treatment techniques: autologous tissue that is of the same patient (muscle-skin flaps), with skin expanders and / or prosthesis, with flaps and implants.
In cases where the pectoral muscle is preserved and the overlying skin is sufficiently trophic and abundant to coat a mammary cone is possible the reconstruction with only the insertion of a breast implant. This solution can, however, rarely implemented. Most frequently are inserted expandable prosthesis, which are also placed under the muscle plane and later expanded with saline to increase the breast rebuilt space. This type of prosthesis is typically used when the volume to be reconstructed is contained.
Mammary expanders are widely used today both in the immediate post-mastectomy reconstruction, both in deferred. Their use allows to give a more natural form of breast reconstructed. The expander is placed under the pectoralis major and below the median edge of the serratus muscle, another chest muscle. Once entered, it is filled with saline solution during the following weeks, usually for a few months, through a valve inserted into expander same until you reach the desired volume. This determines a tissue distension and the creation of a sufficient pocket to accept the prosthesis. During the next few hours to inflate properly ‘expander you can experience discomfort and sense of breast tenderness.
Reached the desired volume, expect another 5-6 months to allow adjustment of the patient’s tissues. In the second operation the expander is removed and replaces it with the permanent prosthesis, after performing the ‘removal of its capsule. To date more than 3 million women are carriers of implants containing silicone gel.
Reconstruction with tissue transfer
Muscle flap Grand Ridge
This technique is used when there is not an adequate amount of good quality skin to cover the breast implant. The flap, which also includes the fascia, is drawn starting from the inframammary fold and is extended laterally. It is transferred by turning it approximately 90 ° to fill the scar area. It is then positioned a prosthesis under the muscle plan because muscle is very thin and does not ensure enough volume. This technique allows to solve without expansion only time a breast reconstruction. The scars are more spacious but remain largely confined in the bra cup.
Musculocutaneous flap of Grand Ridge
The use of this flap is reserved for situations where there is a need to replenish both the skin and the muscle, thus replacing the pectoralis major muscle that can be atrophic after radiation treatment or even absent for more radical demolitions. You generally have to integrate volume even with a prosthesis. The flap of latissimus dorsi is a viable alternative to the reconstruction with rectus abdominis even though it is more suited to rebuild not very voluminous breasts or to restore deficits showy quadrantectomies.
Flap of rectus abdominis musculocutaneous (TRAM flap)
This technique allows to reconstruct a large volume breast and adapt it to a contralateral breast ptosica (drooping) and voluminous. And ‘it possible to transfer in the mammary region wide area of skin and adipose tissue located in the lower abdomen, below the navel. The advantages of this flap are the following: the significant contribution of the skin with its subcutaneous adipose mantle and sufficient to restore a large breast volume and ensure a good aesthetic result with a breast naturally ptosica; We do not use implants but only tissues of the same patient.
This technique has several disadvantages:
• a wide horizontal abdominal scar in the donor site of the flap
• the weakness of the abdominal wall with the possibility of incisional hernias (hernias) Secondary
• The operating time is long, 4-5 hours.
• Then there are contraindications: severe obesity, smoking, diabetes, microvascular disorders.
Musculocutaneous flap of Gracile (TMG flap)
This technique allows the reconstruction of a small volume of the breast and the nipple in a single time. And ‘it possible to transfer in the mammary region an area of skin with adipose tissue and muscle placed in the superior part of the inner thigh. The advantages of this flap are the following: a good aesthetic result with a nipple already reconstructed; We do not use implants but only tissues of the same patient, making a thigh lifting is taken from where the flap
This technique also has several disadvantages:
• extensive cross groin scar in the donor site of the flap
• skin with darker pigmentation than that of the chest
• the inadequacy of the flap to reconstruct large and medium-sized breasts
• The operating time is long, 3-4 hours.
• Then there are contraindications: severe obesity, smoking, diabetes, microvascular disorders.
Correction of the contralateral breast
Breast reconstruction, excluding the technique with musculocutaneous flap of the rectus abdominis muscle, leading to a conical breast and not ptosica. It follows that very often in order to remedy this asymmetry need to intervene on the contralateral breast (the opposite side) in the following ways:
Correcting the degree of ptosis with mastopexy (breast lift) balancing; reducing the volume with an actual breast reduction; increasing the volume with a calibrated breast augmentation.
E ‘preferable to perform the symmetrization of the contralateral breast in a second operation, after at least six months from the first, to enable the contralateral breast a result of stabilization.
Then there are various technical alternatives such as the use of two rectus muscles together, in order to transfer greater amount of fabric can, or the use of microsurgical techniques (DIEP flap) in order to save muscle tissue and decrease the risk of secondary incisional hernias (hernias abdominal).
Preparing to ‘intervention
L ‘action should not be performed in pregnant patients. A month before going suspended l ‘eventual progestin therapy (pill) to decrease the risk of thromboembolism, and also smoking. Two weeks before you will have to suspend the ‘intake of drugs containing acetylsalicylic acid (sucks, etc.). In some cases, Dr. Grassetti sees fit to make you do one or two donations of blood as they become necessary in the course of ‘intervention or post-operatively in order to reduce the’ anemia. The day before the ‘intervention must be made a bathroom complete cleaning, remove nail polish from unghiedi hands and feet, armpits depilated. Before the ‘intervention must be observed fasting for at least 8 hours.
In the post operative period it can be felt in the pectoral region some pain, controlled with standard analgesics, which regresses within a few days.
The suction drains are removed when the amount of fluid drained in the 24 hours will be less than 30-40 ml.
In the case of reconstruction with implants / expander, you will have to wear a bra elastic restraining with front lacing, to buy before admission. It must be also provided with an elastic band from ‘high downward and is worn for two months’ s intervention, in order to maintain within the’ system until the formation of periprosthetic capsule.
For the first 4 days post-operative rest is recommended with particular attention to the maneuvers involving the pectoral muscles to force them on the arms to get out of bed or lift weights. A bed should rest with the torso raised. It should avoid smoking for both of bleeding possibility that for stimulation of the cough.
For the first two weeks it should be avoided driving. The first stitches are removed 7-10 days after the ‘intervention it will be carried out when the first shower.
For about a month will have to be avoided any kind of sporting activity.
They may be of a general nature, as in all surgical procedures: hematoma, seroma, infection, spontaneous reopening of the wound and decreased skin sensitivity. The hematoma, if a large scale can also lead to a return to the operating room to drain.
Then there are specific complications of the practiced type of intervention.
In the case of reconstruction with autologous tissues can be confirmed, albeit rarely, necrosis of the flap (up to 5% of cases) that may result in the return to the operating room, the liponecrosi autorisolventesi, the difficulty in wound healing, asymmetry in the breasts , post operative hernias in case of withdrawal of the rectus muscle of ‘abdomen (hernia secondary).
If you have opted for a reconstruction with prosthetic material, you can attend the periprosthetic capsule contracture (up to 20% of cases), dislocation, exposure and rarely implant rupture, all eventualities which, although rare, can also result in the return in the operating room within weeks or months after the first operation.
Reconstruction of the nipple and areola
The last step of the breast reconstruction is the reconstruction of the nipple-areola complex, which is performed when the breasts are well-balanced and stable. The nipple can be reconstructed using the contralateral nipple: if ‘s is big and very protruding you can pick half and transplant it as a free graft in the new headquarters. Alternatively, numerous methods have been described that use small local flaps taken from the same of the mastectomy scar, which, rotated, simulate the appearance of a nipple and which represent the preferred technique by Dr. Grassetti. The projection of the nipple tends to also decrease by more than half of the original one in ‘next year’ s intervention!
The areola can be reconstructed with a graft or a skin graft taken at the root of the thigh, or you can get good results with dermopigmentation via tattooing. The latter has the advantage of not requiring an operating room and especially not to add other scars, but tends to discolor over time more rapidly compared to ‘other method described above.