Prof. Dr. Moustapha Hamdi offers you different types of plastic surgery, both for aesthetic and reconstructive surgery. As the term itself says a reconstructive procedure restores or improves the function of a body without damaging its shape. This is for instance the case with the remodeling of a breast after a (partial) amputation.

That as opposed to aesthetic surgery, where the aim is to restore the shape or to create without compromising its function. As an example, rhinoplasty should never alter a patient’s sense of smell.

Breast Reconstruction

“The breast is one of the most noble parts of the body. It has always been my passion to be able to remodel it.”
“When I was studying at the University of Damascus, Dr. Karl Hart Rampf showed us a breast reconstruction on TV as a part of our training, but for me it was the moment I decided to become a plastic surgeon. A few years later, after I graduated, I had the opportunity to spend some time in the hospitals of the ULB in Belgium. I learned the need to know mammoplasty and reconstructive breast surgery. I also started to evaluate the existing techniques in that field which ultimately led me, along with some colleagues from Ghent, to develop my own technique. This technique has now been extensively tested and is used, adopted and applied throughout the medical world.”

The need for breast reconstruction
Breast cancer is a common condition amongst women. Almost one in ten develops a tumor in one or both breasts during the course of her life. During the last twenty years doctors diagnose more patients with breast cancer. However, that does not mean that the condition is actually more common. The progressive aging of the population and the larger population are just some explanatory factors for this increase. In addition there have been large scale population screenings since 1988, detecting tumors more rapidly and more frequently. It is in fact this research that ensures that fewer patients die from breast cancer.
The treatment
To fight breast cancer, there are various treatments. For some women, it is sufficient to remove the tumor and some healthy tissue around it (tumorectomie). In this case we speak of breast-conserving surgery. Usually, these patients also received a treatment with local radiation therapy to reduce the likelihood for the tumor to returns.

For other women, there is no other option than to take away the full breast (mastectomy). They also receive radiotherapy or chemotherapy treatment. In other cases, a hormonal post-treatment has a favorable effect.

What happens after a mastectomy?
Not every woman reacts in the same way after a mastectomy. One will have a breast reconstruction performed, and preferably as soon as possible, while others prefer to wear an external prosthesis.

Or maybe you prefer to do nothing.
Know that what you want is a personal choice that you must make for yourself. But to make that choice, it may help if you know all the diffeerent types of treatment and reconstruction options.

When should I consider a reconstruction?
Classic mastectomy
Skin-saving mastectomy

A breast reconstruction does not have any influence on the course of the disease. It has, in other words, no negative impact on the treatment or its evolution. But it will often provide a better quality of life for the patient. Therefore, your surgeon can perform a breast reconstruction immediately after the tumor has been removed. It’s called a primary or concurrent reconstruction. It is however preferable to wait a bit so you can choose a secondary or delayed reconstruction. Your surgeon then performs a reconstruction in about six to twelve months after the actual amputation or after your treatment is over.

Both reconstructions have their advantages and disadvantages.
We have listed them here for you:

Primary reconstruction

Advantages

  • Two operations at one time
  • Psychological advantage
  • Aesthetic result is usually better
  • Improved wound healing

Disadvantages

  • Radiation can cause calcification in the breast

Secondary reconstruction

Advantages

  • Poor skin quality because of for instanceradiation therapy does not affect the result

Disadvantages

  • Wound healing can sometimes be a little more difficult
Which technique is best suited for me?
There are various techniques to perform a breast reconstruction, but not every method suits every woman. Your surgeon will find and suggest a suitable technique depending on a set of variables:

  • Age
  • Physique
  • Breast form and volume
  • Any (and all) previous operations
  • Type of surgery to the breast (tumorectomie vs mastectomy)
  • Possible aftertreatment
  • Your personal preference

Each technique has its advantages and disadvantages. Your plastic surgeon will take all factors into account and bring the various options to the table.

The different techniques
As previously mentioned, there are several techniques for breast reconstruction. A first factor determining which technique is suitable for you, the size of the removed tissue and the size of your breasts.
If the surgeon did not perform a complete breast amputation (tumorectomie), you can choose from a number of partial breast reconstructions:

  • Reconstruction with a local tissue flap
  • Breast reshaping
  • Reconstruction with pedicled flap
  • Reconstruction with a free tissue flap

If a complete breast amputation (mastectomy) was your only option, there is no other option than a total breast reconstruction. Such total reconstruction may consist of your own body- or foreign body material. Again in these two categories different techniques are possible.

Foreign body material

  • Water filled prosthetics
  • Silicone filled prosthetics
  • Tissue expanders
Your own body material

  • DIEP of belly flap
  • SGAP of buttock flap
  • TMG of thigh flap

Partial Breast Reconstruction (after a tumorectomy)

Reconstruction with a local tissue flap
If your surgeon only has to remove a small portion of the breast he can fill it with a local flap from the breast or armpit. If he uses tissue from your armpit, you have to take an additional scar into account.
Reconstruction by breast reshaping
Do you have a large breast volume and the amount of removed breast tissue is less than thirty percent of the total volume you can choose to have a tumorectomy combined with a breast reduction. The surgeon then uses the remaining tissue to create a new smaller shape breast.

This technique is also a possibility if the tumor was already removed in the past which deformed the chest significantly.

The scars that will remain after this procedure are located in the same place as a classic breast reduction, namely around the nipple and around the lower pole of the breast.

Reconstruction with pedicled LD (latissimus dorsi) or Tdap (thoracodorsal artery perforator) flap
If it was sufficient to remove less than thrity percent of your total breast volume this could still leave you with a rather small remaining amount of breast material, possibly not enough for reshaping the breast. There would simply be too little tissue remaining after the surgery. In that case, you surgeon can harvest additional tissue from a different part of your body. In this case there are two possible techniques.

For a reconstruction with a pedicled latissimus dorsi flap, the surgeon loosens a large back muscle on the same side as the operated breast. He brings that flap around to the chest to fill it. The major disadvantage of this procedure is, however, that one of the major muscles of the body is sacrificed.
Another possibility is, therefore, a reconstruction with thoracodorsal artery perforator flap. During this procedure your surgeon only loosens the skin and fat from the back to use this flap to fill the chest. The muscle remains untouched.
Both techniques involve a remaining scar on the back which can be oriented diagonally upwards to the spine, along the lines of the skin folds, or if prefered horizontally hidden under the strap of a bra.

Reconstruction using a free tissue flap
In some cases, the surgeon has to remove more than thirty percent of the breast tissue. In that case, the amount of tissue removed is too large to use flaps from the back to fill. The result will be aesthetically more beautiful if your surgeon removes all breast tissue and completely replaces it with tissue from a different place. The techniques for this purpose are the same as the ones applicable after a mastectomy, namely a transplant from home- and adipose tissue using microsurgery.

Total Breast Reconstruction (after a mastectomy)

Reconstruction using foreign material
A breast prosthesis consists of plastic, of which the wall is usually made of soft silicone. That wall is both smooth and rough (textured), but nowadays surgeons almost always opt for a rough wall. These prosthetics lead less often to capsular contracture.
The contents of these prosthetics is most commonly physiological water or cohesive silicone gel.
A small overview of advantages and disadvantages for both materials:

Waterfilled prosthetics
Water Filled prosthetics have the important advantage that they contain a product of which your body itself is largely built. If your prosthetic ruptures, then your body will resorb the water and excrete it through the kidneys. Because your chest ‘falls flat’, you will notice that your prosthesis is leaking. The disadvantage is that water-filled prosthetics feel less natural, and that the rim is sometimes felt under the skin. In some cases, the skin can also show a form of wrinkling.

Silicone filled prosthetics
These implants contain a cohesive silicone gel, which can be compared to a lump of gelatin. The gel feels soft, but does not matter if you cut the shell.
The advantage of such prosthetics is that they provide a more natural feel due to the anatomical shape of the gel (a so-called droplet form). This prevents the upper pole of your chest to appear abnormally filled. The main disadvantage is that the silicone gel doesn’t naturally occur in our bodies. Yet you can be confident that they are safe and do not cause disease. Another disadvantage of silicone-filled prosthetics is the slightly higher cost.

Tissue expanders
If after your mastectomy insufficient skin for the reconstruction remains, but the remaining skin is of good quality, you can opt for tissue expanders. These are inflatable prosthetics through a fine tube with a valve connected to them. A valve through which the surgeon can refill the implant. The procedure is performed in several steps.
In a first phase, your surgeon places an expander beneath your skin and chest muscle, which he can gradually inflate after about two or three weeks. This will stretch the muscle and skin creating room for a definitive prosthesis. When the correct volume is reached, the surgeon replaces the expander with a definitive one during a second operation. There are also permanently expandable implants. They do not need to be replaced which in turn removes the need of a second operation.

Advantages

  • Reconstructions with implants are technically relatively simple procedures, for which a limited operation time is needed and involving low amounts of complications
  • There are no additional scars
  • The hospital stay is usually slightly shorter
  • Tissue expanders allow the volume to be adjusted after surgery

Disadvantages

  • The longer the implant is in place, the greater the risk of complications.
    Especially capsular contracture is very common. The prosthesis is indeed a strange object, which the body tries to encapsulate. That contracture should always surgically treated and there is no guarantee that the problem does not recur later
  • There is a higher risk (to what?), but placing the implants behind the pectoral muscle sites, provides some protection
  • There is a greater chance of infection
  • Implants suffer from wear and tear and will have to be replaced at some point
  • The aging process of the implant is different than that of the body, with an increasing asymmetry as a result
  • The prosthesis does not evolve along with the weight of the patient
  • The aesthetic result is inferior to a solution with your own tissue, not only in appearance but also in terms of feel and durability
  • Because the chance that multiple interventions, even afterwards, are needed, the total cost of a foreign tissue reconstruction will be higher
Reconstruction with your own body tissue
The DIEP (Deep Inferior Epigastric artery Perforator) or belly flap

Your surgeon harvests skin and adipose tissue from the abdominal region and transplants it to the chest. Before he closes the wounds, he creates an optimal breast shape from the piece of abdominal tissue. He brings the wound edges of the abdominal wall together in order to close the abdominal wall, just like a tummy tuck. After surgery your belly will be flatter and more stretched, which for some women is a nice perk.
The remaining scar will be running from one side of the upper hip to the other side. But it is low enough to be hidden under normal pantys or a bikini.

The SGAP (Superior Gluteal Artery Perforator) or buttock flap

Unlike with the DIEP flap the surgeon transplats the skin and adipose tissue from the buttock to the chest. The technique of the procedure is the same as with the DIEP flap procedure.
The scar runs from one side of the buttock to the other, but you can cover it with normal underwear. It may be, however, that the contour of your buttock slightly changed. Also, the fatty tissue of the buttocks is slightly more consistent than that of the abdomen, so that the breast may feel less soft and the surgeon may have difficulties creating an ideal breast shape. Therefore he usually does follow-up surgery six months after the initial operation to correct the form.

The TMG or thigh flap

In this procedure, the skin and adipose tissue at the level of the upper inside of the thigh is aspirated and then transplanted into the chest cavity. In this kind of reconstruction a piece of the gracilis muscle (a secondary muscle that helps the adduction of the leg) is included in the flap, together with a nutrient pedicle.

In most cases, the patient experiences little or no load placed at the height of the donor flap. The technique for positioning of the flap in the breast, and the connection of the blood vessels can be to be compared with that of the belly flap. The scar at the level of the donor site is running on the inside of the thigh, from the front of the groin to the rear under the buttock fold. This scar can be covered by normal underwear. It is true that there is possibly a more or less pronounced depression around the contours of the inside of the thigh, so that this flap is a second choice for breast reconstruction after the DIEP flap.

The indicator of choice is a unilateral or a bilateral immediate breast reconstruction for women who have inadequate fat around the abdominal area. With this flap it is often necessary to correct the reconstructed breast around three months after the primary surgery.

Advantages
As opposed to a reconstruction with foreign body tissue, the advantages of a reconstruction with autogenous tissue increase over time.

  • The longer one’s own tissue is present, the less chance of complications
  • The aesthetic result improves over time : the breast increasingly gains a more natural shape and scars fade
  • The breast feels warm and natural
  • The body’s own tissue follows fluctuations in weight and also follows the normal aging rhythm of the body
  • There are fewer late surgical corrections
  • The total costs in the long term is lower
  • A reconstruction using your own tissue is not a problem when treated with radiotherapy before or after surgery

Disadvantages

  • A reconstruction with autogenous tissue requires a greater investment in the initial phase
  • The procedure is more complex
  • The surgery takes longer and there is a small risk of complications
  • The hospitalization and rehabilitation usually last a little longer
  • There is an additional scar

Clinical images (pdf)