It is an intervention intended to return the breast to its natural state. It is usually indicated in patients who have undergone breast cancer mastectomy interventions.
The ideal concept would be to return the breast to its natural shape and volume, including the areola and breast nipple. To achieve this we have multiple techniques, from the simplest to the most sophisticated. Reconstruction with implants, with one’s own tissue flaps or microvascular surgery.
The reconstruction with expanders consists of achieving a two-stage reconstruction, indicated mainly in patients who have not been (pre or post operatively) irradiated with radiotherapy, since this type of treatment entails a great loss of skin elasticity that makes expansion difficult and leads to a great number of failures with this technique.
The aim of this technique is to achieve a breast with a natural appearance that retains good symmetry with the contralateral breast, as in many cases the second surgical stage can assess the possibility of reducing, elevating or increasing the symmetry of the contralateral breast.
In the first surgical stage, an expander prosthesis is introduced sub-pectorally. This expander has the characteristic of being two-dimensional, i.e. it expands both in width-height and projection. There are now expanders with a wide range of measurements and projections that are each time more intense. This solves the old problem of the lack of breast projection that is obtained with these techniques.
The expansion process begins in about 20 days, after checking that the healing has been correct and the surgical sutures have been removed. The rapid expansion involves a consultation with the patient every 10-15 days to fill the expander with a saline serum until reaching the maximum volume or with a slight overfill.
The second surgical stage is intended for the replacement of the expander with a definitive prosthesis, which has previously been chosen by the surgeon according to the measurements and assessments made in advance. Anatomical implants are normally used to offer more natural results. Surgery can be used to symmetrize the other breast with some reduction-mastopexy technique or breast augmentation at the same time.
The third and last surgical stage of breast reconstruction tissue expansion, is intended for the areola-nipple complex. It is usually performed with a local anaesthetic and the most common is to use the local skin tissue to rebuild a nipple plus a semi-permanent tattoo for the areola. Skin graft can also be taken from the groin or the contralateral nipple.
Breast reconstruction with the dorsal broad muscle is a technique of reconstruction classified within the techniques that use one’s own tissues.
To restore normality in the breast after a mastectomy the skin of the back at the height of the scapula is used and as a vascular support vehicle, the muscle below it, the dorsal width. It is a technique indicated for patients who have undergone radiotherapy and have a cutaneous deficiency in the mammary area in addition to a lack of elasticity of the same.
Since the use of this flap does not allow a sufficient amount of volume to be symmetrical with the contralateral breast, in most cases a sub-muscular filling prosthesis is often used simultaneously.
The contralateral breast should also be evaluated, which can be re-modelled with a pexia, an increase or reduction depending on the case.
This technique achieves very good results despite the skin of the back having different characteristics to the skin of the thorax in terms of thickness, texture and colour. A wide scar can follow in the back in the line of the bra strap or to be descending by the lateral edge of the dorsal muscle.
DIEP breast reconstruction is classified within the group of reconstructions with autologous tissues, that is to say, their own tissues.
In it, the fat and the skin of the abdomen is used to reconstruct a breast, these tissues being the most similar in colour, texture and consistency with those of a natural breast. It is therefore, the most natural method of breast reconstruction and provides better results. Though it has the disadvantage of requiring microvascular surgery, it does not represent a habitual intervention in hospitals that require centres specialized in reconstruction microsurgery.
DIEP breast reconstruction is thoroughly prepared during the consultation process through an exhaustive study of the patient and her needs. The shape of the breast to be reconstructed, its volume and its projection is also assessed. It should also be considered whether the abdominal donor area is suitable for this flap, since the ideal patient should possess a certain amount of fat in the lower abdominal area. In order to locate the perforating vessels and receptors that are more suitable for reconstruction, pre-operative studies such as Doppler ultrasound and the angio TAC need to be performed.
DIEP breast reconstruction may be contraindicated in patients with previous abdominal surgeries, who, because of scars, may have compromised the vascular pedicles of the flap; This is common in patients with previous laparoscopies, large caesarean sections, cholecystectomies, abdominoplasty, etc. It may also be contraindicated in patients who smoke or have forced themselves to stop smoking in the previous 6 months.
The DIEP breast reconstruction consists of lifting all the abdominal fat tissue and the skin of the portion between the navel and the pubic area and transferring it to the mammary area. This tissue is raised with an arterial and venous vascular pedicle (or several) that connected to the thoracic vessels will ensure blood flow to the flap.
Once the flap is transferred to the thoracic area, the surgeon positions it and gives it the appropriate shape to simulate a breast. At the same time the wound is sutured and closed. In the abdominal area, the rectus abdominis muscle and motor nerves are valued, which, unlike other techniques such as TRAM, prevents the appearance of the dreaded complications of post-operative hernias.
The closure is performed as a tummy tuck so as to aid the aesthetic correction of the abdomen.
With regard to functioning of the abdominal flap, if the patient suffers episodes of an increase or decrease in weight, the flap will evolve in a similar way to the contralateral breast. This is a type of reconstruction with very natural and lasting results thereby integrating the flap in the anatomy of the woman perfectly.
In the case of breast reconstructions, general anaesthesia is used except in the reconstruction of the areola-nipple which is performed with local anaesthesia.
It varies depending on the method used. This being reconstruction surgery with expanders, surgery lasts about 45 minutes in both stages with a hospital stay of usually 24 hours. Recovery is quick, with some discomfort or tension felt in the breast area for the first 5-6 days.
For the dorsal flap, two hours of surgery and a hospital stay of 48 hours are usually required. The post-operative care evolves more slowly during the course of 2 weeks with pain in the back area usually controlled with analgesics. Seroma may appear in the posterior area which is sometimes necessary to drain.
Being more sophisticated, reconstruction with DIEP flap requires about 4-6 hours of surgery with about 3-4 days of hospital care. There is some discomfort and tightness in the abdominal area during the post-operative phase and there is slight pain in the mammary area. Complete recovery can take about 3 weeks.
Frequently Asked Questions about Tissue Expansion Technique
Yes, there are many techniques, and they can be divided into two large groups. Those that use breast implants and those that use one’s own tissue such as the dorsal muscle or the rectus abdominis muscle.
Until a few years ago oncologists advised mastectomized patients to wait for at least 5 years (disease-free interval) to consider a breast reconstruction. Now, due to the improvements in diagnostic measures, breast reconstruction is performed earlier, even being able, in some cases, to be performed simultaneously with the mastectomy. In this variant of immediate reconstruction, the patient avoids the suffering of seeing the body mutilated with mastectomy, which results in better psychological recovery after breast cancer.
Frequently Asked Questions about Dorsal Broad Muscle Technique
After the procedure, there is usually pain in the operated area and functional limitations in moving the arm on that side. In about 10-12 days the symptomatology improves and patients after 2-3 weeks, are able to perform normal activities.
Regarding physical exercise or muscular exertion, it should be noted that it may require a longer period of time or there may even be a small loss of muscular strength in the area before practicing sports such as climbing, cross-country skiing, swimming, etc.
It is very difficult in a complete reconstruction mastectomy not to have to use an implant, because the volume contributed by the muscle and the skin is usually insufficient. In case of quadrantectomies or lumpectomy it is possible to use a small dorsal flap as the only tissue to reconstruct without implants.
Aesthetic results are very good in terms of breast reconstruction. Scars on the back produce a sizeable impact that the patient must accept prior to undergoing this type of intervention. The difference in thickness and colour in the skin of the reconstructed breast and the fact of having to use a silicone implant are considerations that patients should bear in mind.
Frequently Asked Questions about DIEP Breast Reconstruction
The most frequent complications may be partial losses of the flap due to necrosis (due to poor planning of the flap) and poor selection of the patient. Pneumothorax, mammary asymmetries, hypertrophic scars, pulmonary embolisms, etc. can also occur.
It will depend on the amount of donor abdominal tissue, but it is possible to perform a double reconstruction at the same time.
The methods of reconstruction with one’s own tissues present the advantages of being more natural and avoiding the inconveniences of the use of breast implants. Replacement of breast implants with abdominal tissue flaps is also common in patients who have had reconstruction surgery years ago. Reconstruction with implants does not have to be for life and its replacement with these flaps is the most appropriate step.
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