After Breast Cancer when is it best for implant reconstruction?
At what point is it ideal to undergo breast cancer surgery for implant reconstruction?
Hello, it's THE Plastic Surgery Clinic.
Today, I'd like to discuss the optimal timing for implant reconstruction following breast cancer surgery.
In general, it's common for implants to be placed right after breast cancer surgery, or for breast reconstruction to take place once the wound has partially healed. The timing of surgery varies, with immediate reconstruction involving simultaneous reconstruction during resection and delayed reconstruction occurring at a later time after resection. This discussion will cover the procedure of conducting surgery within 1 to 2 weeks following breast cancer surgery, known as immediate reconstruction.
At our clinic, we suggest performing breast reconstruction after the conclusion of radiation therapy. This recommendation is based on the common occurrence of changes, such as capsule formation around the implant, during radiation treatment. These changes may significantly affect the structural integrity and increase the risk of misalignment. If radiation therapy is not scheduled, immediate reconstruction is a viable option. However, if radiation therapy is planned, we advise a slightly delayed approach before proceeding with reconstruction.
The challenge lies in the inability to definitively ascertain the need for radiation therapy before surgery. The final decision regarding radiation therapy depends on the confirmation through tissue analysis, usually available approximately 4-5 days post-surgery. For instance, there are situations where despite initial assumptions of not needing radiation therapy, its necessity arises after the surgery. hence, it's crucial to proceed with surgery only after the comprehensive hisopathological examination results are obtained.
Breast tissue hosts a substantial amount of bacteria, interconnected to the nipple through ducts that contain minute, unseen openings. Skin bacteria, known as normal skin flora, can enter the breast tissue through these ducts. Breast cancer surgery involves extensive handling of this tissue, despite meticulous cleansing, presenting a notable risk of contamination. Waiting for a week or ten days after antibiotic treatment before surgery can markedly reduce the likelihood of contamination, as the area tends to be considerably cleaner post-treatment.
When initially diagnosed and contemplating reconstruction, it's often challenging to envision the immediate shape or size of the future breast. Additionally, discussing these concerns with the surgeon may be emotionally difficult without proper mental preparation. Hence, opting for surgery first, achieving stability, and then engaging in discussions allows for a more profound and informed conversation.
Finally, in terms of technical expertise, there has been a prevailing trend in breast reconstruction to place implants above the muscle. However, in over 90% of breast augmentation surgeries, the dual-plane technique or sub-muscular placement is preferred. This preference stems from the potential issue of the skin appearing excessively thin and potentially revealing the implant outline when placed above the muscle. Breast excision surgery involves the removal of breast tissue and adjacent fat, leading to thinner skin. Consequently, placing implants above the muscle might result in an unnatural appearance.
Therefore, our clinic trends to avoid placing implants above the muscle in breast reconstruction. While there might be a few reasons necessitating or favoring this approach in immediate reconstruction, opting for immediate reconstruction allows us to perform the procedure in a stable manner using the dual-plane technique.
I will demonstrate how the space for the implant can be different in immediate and delayed reconstructions using a model.
When undergoing breast cancer surgery, the skin remains intact, and a breast-conserving procedure is performed. As mentioned earlier, placing the implant above the muscle can significantly increase the chance of visible edges. When positioned beneath thin skin, the implant may become prominently visible.
The most effective approach in this case is placing the implant beneath the muscle. In situations where the muscle extends too low, a partial release might be required. This technique, known as the dual-plane method, involves inserting the implant so that the lower part remains uncovered by the muscle, while the upper part is covered. It's currently on of the widely practiced methods in breast augmentation surgeries in Korea.
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Why isn't this approach used for immediate reconstruction?
Previously, due to the attachment between the breast tissue and the muscle, cutting that area did not yield substantial lift. However, post breast cancer surgery, as there's no supporting structure to retain the muscle after cutting, it causes the muscle to elevate entirely to the top. Consequently, this method leads to a scenario where implementing the dual-plane technique on top of the muscle doesn't significantly differ from the other case.
will use a model to demonstrate how the space for the implant can be adjusted differently for immediate and delayed reconstructions.
When a breast cancer surgery is performed, it typically involves a breast-conserving operation where the skin remains intact. As mentioned earlier, placing the implant above the muscle increases the probability of noticeable edges. If inserted beneath thin skin, the implant may become prominently visible.
The next commonly used method involves connecting the end and base of the muscle to a synthetic skin substitute. This approach was utilized to use the artificial skin substitute like muscle, considering the pulled-up muscle. However, there were limitations in terms of the aesthetic outcome, which I'll explain.
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Due to the muscle lifting upwards, the practice involved utilizing a synthetic skin substitute to connect the tissue beneath it. However, the problem with the synthetic skin was its lack of elasticity. leading to poor stretch-ability. Consequently, the expander shape started distorting, inflating in an uneven manner rather than its intended original shape. Let me demonstrate this issue.
Tissue expanders gradually inflate at regular intervals and come in specific shapes and sizes, making decisions on the expension amount and pattern critical. Dermining the expander's shape is crucial for aesthetic considerations. A misjudgment in this process can lead to overall distortion. I'm explaining that the mismatch in the expansion of muscle and skin versus the synthetic skin caused the shape to become irregular.
Because merely replacing the implant does not change the shape, the objective is to position the implant on top of the muscle, not just the expander. This approach aims to achieve a more natural shape for the breast. Ultimately, I prefer placing the implant using the dual-plane technique or using the expander to maintain a more natural appearance.
After approximately ten days, the muscle begins adhering to the skin on the surface and slightly to the subcutaneous tissue below. As a result, when the muscle is released, there isn't significant elevation, allowing for a smooth execution of the dual-plane technique. This capability stands as a notable advantage in delayed reconstruction that I'd like to emphasize.
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