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 decades, more cases of breast cancer were found in the population. This rise in incidence might be due to longer life expectancy but also because of more quick and large screening scale in the country. Early tumor detection and more aggressive treatment of breast cancer resulted in less patients death from breast cancer.

To fight breast cancer, there are various treatments. For some women, it is sufficient to remove the tumor and some healthy tissue around it (tumorectomy). In this case we speak of so-called breast-conserving surgery. Usually, these patients also receive a treatment with local radiation therapy to reduce the likelihood for the tumor to return.
For other women, there is no other option than to take away the full breast (mastectomy). They also receive radiotherapy or chemotherapy treatment when indicated.

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. Some even prefer to do nothing.
It is a personal choice that you must make for yourself. But to make that choice, it may help if you know all the different types of treatment and reconstruction options.

Classic mastectomy: The breast gland is removed together with the nipple-areola complex and most of the breast skin resulting in an horizontal or oblique scar.

Skin-sparing mastectomy: The breast gland is removed together with the nipple-areola complex but most of the breast skin will be spared resulting in less scars.

Nipple-sparing mastectomy: The breast gland is removed but the nipple-areola complex and most of the breast skin are spared resulting the most aesthetic result. It is indicated in prophylactic mastectomy (patient with high risk of breast cancer) or in very indicated cases of small tumor which are located far from the nipple.

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

• Less stressful to the patient as all treatments are behind the back
• No influence of the radiotherapy of the flap

Disadvantages

• Wound healing can sometimes be a little more difficult if radiotherapy was given.
• More skin should be replaced which might make a patch-effect.

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
• Body morphology
• 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.

As previously mentioned, there are several techniques for breast reconstruction. A first factor determines 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 (tumorectomy), you can choose from a number of partial breast reconstructions:

• Reconstruction with a local tissue flap
• Breast reshaping/remodeling
• 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/SIEA flap or belly flap
• SGAP flap or buttock flap
• LAP flap or love-handle flap
• PAP flap or posterior thigh flap
• TMG/TUG flap or median thigh 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.

If 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.

If it was sufficient to remove less than 30 % 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, your 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 uses the skin and fat from the back 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 preferred horizontally hidden under the strap of a bra.

When the surgeon has to remove more than 30% of the breast tissue, a total removal of the breast is better indicated and therefore a mastectomy will be done. The reconstructive techniques are the same as the ones applicable after a mastectomy.

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. More recently, Polyurethane cover implants have proved their superiority in term of less capsular contracture and long-term aesthetic results.

The contents of these prosthetics is either physiological water or cohesive silicone gel. Nowadays, Silicone cohesive-gel implants are much more sued than water filled implants.

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. Another indication for expander is when there remains a potential risk of having radiotherapy after the mastectomy. The expander is used as a “baby-sitter” to keep the breast skin during the radiotherapy. The expander will be removed 6 months after the end of the radiotherapy and replaced by a silicone-gel implant or mostly with a flap. This procedure called “delayed-immediate” reconstruction.

These are inflatable prosthetics with a valve integrated to the implant shell, 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 foreign body, which the human body tries to encapsulate. That contracture should always surgically treated and there is no guarantee that the problem does not recur later
• 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 using with your own tissue (flaps), 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

The DIEP (Deep Inferior Artery Perforator) or Belly (Tummy-Tack) flap

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Your surgeon harvests skin and adipose tissue from the abdominal region and transplants it to the chest. It is the most common used donor site because it provides ample amount of skin and soft fat. The abdomen skin has similar skin color as the breast.
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. A variation of this flap can be used when the superficial vessels of the lower abdomen are big enough in the patient, SIEA flap.

The TMG/TUG or thigh flap

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When the abdominal tissue is not available because of previous scars or thin abdominal wall, the upper thigh present an alternative donor site. 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.

With this flap it is often necessary to correct the reconstructed breast around three months after the primary surgery using fat grafting (lipofilling).

The Other flaps “Exotic Flaps”

When neither abdomen nor upper thigh are available for breast reconstruction, surgeon looks for other donor sites such as the buttock, the flancs or back thigh. Those the flap have less acceptable donor site aesthetically and the resulted scar should be clearly discussed with the patient before surgery.

The LAP (Lumbar Artery Perforator) or flanc (love-handle) flap 

The technique of the procedure is the same as with the DIEP flap procedure, but the surgeon transplants the skin and adipose tissue from the low back to the chest.

The scar runs from on one side of low back, which might be a bit higher than the underwear or the bikini lines. It may be, however, that the contour of your back slightly changed. Therefore liposuction of the contra-lateral flanc might be necessary give better back symmetry. Touch-up procedure is usually done 4-6 months later.

The SGAP (Superior Gluteal Artery Perforator) or buttock flap

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Here, the surgeon transplants the skin and adipose tissue from the buttock to the chest.

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.

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

Professor Hamdi is a world experience in autologous breast reconstruction (with own body). Flap choice depends on several factors:
• The required tissue for the breast reconstruction (breast volume)
• The body contour of the patient and donor sites analysis
• Patient habits and daily activity
• Technical issues related to the vascular anatomy

The choice of the flap is done after physical examination of the patient but also depending the patient’s wishes and radiological examination of the vessels.

During the last decade, there have been many efforts to avoid flap surgery and achieve autologous breast reconstruction with only fat injection (lipofilling or fat grafting). Fat grafting is ideal technique for soft tissue reconstruction such as breast reconstruction. Using fat grafting, there is no invasive surgery, no large scars and the recovery time is quick. However, this procedure is still unpredictable since fat absorption by the own body is variable and the patient needs multiple session to obtain the required breast volume and shape.
In breast lipofilling, fat survival can be better controled if the BRAVA is applied. The BRAVA is an external bra which was invented by Dr. Khouri from Miami. The BRAVA gently 
expands a woman’s breast tissue making this breakthrough procedure possible for natural 
breast augmentation and reconstruction.The procedure begins with the patient wearing BRAVA while she sleeps for a few weeks. Using the BRAVA creates an adequate matrix for fat to be injected later in an outpatient procedure. After a few weeks of BRAVA wear, Prof. Hamdi removes fat from one area of the patient’s body and meticulously injects it back as hundreds of tiny individual droplets at the breast site that has been enlarged by the BRAVA expansion.

For total breast reconstruction, the patient is planned as follow:

The first session:
Under the effect of BRAVA expansion the mastectomy scar is pulled out, the skin envelope enlarges, and the tight tissues fill up with body fluids to turn into a looser fibrous scaffold with more blood vessels. This process of BRAVA-induced neoangiogenesis requires at least 10 days of expansion before the scheduled surgery.
Fat graft droplets are injected into the scaffold seeding it diffusely and evenly. The fat grafts passively fill up the expanded space. We cannot expect the fat graft to inflate the mastectomy defect beyond what was achieved with BRAVA expansion. This stage will result in a breast mound that is always slightly smaller than the maximal BRAVA expansion effect.

The second session:
Three months later, the second session is planned. Additional BRAVA expansion pulls on the tissue to further stretch the scar, expand the skin envelope, and generate more space and a larger fibro-vascular recipient scaffold. At this stage the patient often requires a larger, deeper BRAVA dome to accommodate the larger breast. More fat graft droplets are meticulously seeded into the scaffold and survive to yield a nice breast mound.

The following sessions:
Variable session should be planned according the required breast volume and the degree of the scar tissue in the post-mastectomy site. Transcutanoeus stitches are used to define the infra-mammary folds and also to enhance the projection (reference. Hamdi et al). Sessions are repeated every three months. A total post-reconstruction reconstruction required 3-6 sessions to complete the breast reconstruction.

In this situation, only a tumorectomy (removal of the tumor with part of the breast) was done. Before partial breast reconstruction, the patient should be first cleared from disease. A detailed report of the previous surgery and oncological treatment is essential. A period of 1-2 years after removal the tumour is mandatory before considering a surgery to correct a post lumpectomy deformity when happened.

Fat grafting:
Lipofilling is considered the first choice for post-lumpectomy deformity because it is simple and non-invasive with less complication rate as compared to other surgical techniques.
When fat grafting procedure is indicated, the surgery can be scheduled with or without using the BRAVA depending of the severity of breast deformity. The more breast deformity, the more lipofilling sessions are required to correct the breast. The BRAVA plays a role to reduce the number of the sessions and the amount of the scar in the breast.

Other technique for partial breast reconstruction:
Similar to immediate partial breast reconstruction, the same techniques can be indicated for delayed partial breast reconstruction. Techniques such as breast reduction or remodelling or flaps are many used depending on:
• Breast volume
• Deformity degree and location
• Patient wishes
• Oncological indication for mastectomy or not