The female breast is a symbol of femininity and sexuality. The loss of one or both breasts as a result of breast cancer means a violation of physical integrity and femininity for many women. In addition to the visual and functional impairment caused by the asymmetry, the psychological well-being often suffers from the physical change. Every woman who suffers from breast cancer is therefore entitled to have her breasts reconstructed.
As early as the end of the 19th century, the German surgeon Josef Rotter developed a method of radical surgery for breast cancer in which the mammary gland and lymph nodes of the armpit were removed. This surgical technique determined the treatment of breast cancer for almost 100 years before the tissue-conserving method (breast-conserving surgery, BCS) in combination with radiation of the breast became established, which is used in most cases today.
The German surgeon Vincenz Czerny performed breast reconstruction with the body’s own fatty tissue as early as 1893, long before breast implants were developed and used to build up the breast.
Both the surgical treatment of breast cancer and the reconstruction of the breast after breast cancer are thus treatments that traditionally fall within the competence of breast surgeons and plastic surgeons.
The formation of breast centers at many hospitals in Switzerland aims to promote cooperation between specialists from different disciplines in order to be able to offer treatment according to current and recognised medical standards to all women suffering from breast cancer. This also includes the various methods of reconstructing the breast, which predominantly fall within the field of plastic surgery.
PD Dr. med. Oliver Scheufler is specialized in breast reconstruction and offers the entire spectrum of techniques available today for breast reconstruction. He is a certified core plastic surgeon at two breast centers in Bern (Breast Center Hirslanden Bern-Biel) and Basel (Breast Center Bethesda-Spital) with over 25 years of experience in reconstructive breast surgery including microsurgical reconstruction of the breast with the patient’s own tissue (free flap breast reconstruction).
when to consider breast reconstruction?
Breast reconstruction serves to restore the female breast, mostly after breast cancer, but also after other diseases that have led to the loss of the breast. In individual cases, it is necessary to discuss with the doctors at the breast center treating you at what point in time breast reconstruction can be carried out on you. The appropriate time for breast reconstruction depends, among other things, on the type of breast cancer (stage) and its treatment (surgery, radiotherapy and/or chemotherapy). The individual prognosis of the breast cancer also plays a role.
Today, 75 to 80 percent of breast carcinomas are operated on in a breast-conserving way (BCS). This means that only the part of the breast containing the breast cancer is removed and the remaining breast tissue is irradiated. However, depending on the size of the tumour in relation to the breast, a significant change in breast volume and shape and a resulting asymmetry can also result here. Therefore, reconstructive surgery can also be useful in these cases to build up the smaller breast after the cancer operation or to reduce the larger mutual breast in order to restore the symmetry of the breast. The reconstruction can often be carried out with the patient’s own tissue (autologous fat), such as the injection of fatty tissue from another part of the body (lipofilling), e.g. from the abdomen or the hip, or by tissue transfer (flap).
In 20 to 25 % of cases, breast-conserving surgery (BCS) of breast carcinoma is not possible because the tumour is too large in relation to the breast or is not limited to a specific area of the breast, or e.g. the breast skin and chest wall muscles are also affected by the cancer. In these cases, the entire breast is removed, which, depending on the particular situation, is possible with preservation of the breast skin and nipple (subcutaneous mastectomy) or may require removal of the breast with the skin envelope and nipple (mastectomy / breast ablation). In both cases, the breast can be reconstructed after completion of the breast cancer treatment, which is possible with a breast prosthesis (expander, silicone implant) or the body’s own tissue (flap, fatty tissue). Especially in these cases, it is advantageous for the breast cancer patient if a detailed consultation about all options of therapy and reconstruction is carried out by a plastic surgeon before the mastectomy. Among other things, the incision for the removal of the breast can be planned in such a way that the later reconstruction is facilitated and the cosmetic result of the reconstructed breast is improved. Some women do not initially wish to have a breast reconstruction after a mastectomy because they are afraid of another operation or do not want to make the decision at the time of the breast cancer diagnosis. In these cases, breast reconstruction is still possible at a later stage, when the breast cancer treatment has been completed and there is a desire to have the breast restored.
Even in the interdisciplinary breast centers, the patient’s decision for a certain form of breast reconstruction is essentially shaped by the primary treating physician, often the gynaecologist. The personal experience and expertise of the breast cancer surgeon have a significant influence on which breast reconstruction procedure is recommended. For this reason, it is advisable to seek advice from a plastic surgeon who is familiar with and offers all breast reconstruction techniques, so that every woman can choose the procedure that is best suited to her needs. PD Dr. med. Oliver Scheufler has over 25 years of experience with all techniques of breast reconstruction and can advise you competently.
Consultation for breast reconstruction
A prerequisite for successful breast reconstruction is careful planning. This begins with your personal consultation at the AARE KLINIK. It is helpful for your surgeon to find out your wishes, ideas and expectations of the operation in order to be able to give you a realistic idea of the possibilities and limitations of the various reconstruction techniques and to select the procedure that best suits your personal needs.
During the physical examination, measurements are made and digital photographs are taken, which are then used for objective analysis and planning of the breast surgery. In addition to the size and shape of the healthy breast, the position and size of the nipple, pre-existing asymmetries of the chest wall as well as the skin quality and any existing scars from the breast cancer operation are important for the planning. These individual factors and your personal wishes help in the joint decision on the most suitable surgical procedure.
It must be carefully considered whether, in addition to reconstruction of the breast, a lift or reduction of the healthy opposite breast is indicated and desired. Depending on the results of breast imaging (ultrasound, mammography, MRI), tissue examination (biopsy) and, if necessary, genetic tests, a bilateral mastectomy and reconstruction may be recommended in individual cases. In cases of familial occurrence of breast cancer, genetic tests can provide important information on the risk of disease in the opposite breast.
The possibilities of reconstruction and the resulting scars on the breast and possibly on other parts of the body will be discussed with you. All risks and possible complications of the operation are discussed with you and the agreed operation is documented on a planning sheet.
In order to plan the operation, we need information from you about your medical history (breast cancer treatment, radiotherapy, chemotherapy, other previous illnesses and operations), other illnesses (high blood pressure, diabetes, thyroid dysfunction), allergies or intolerances as well as possible medication. These are used to assess the risk of surgery and anaesthesia. Please bring all current and important medical findings and diagnoses to the consultation, especially those concerning the breast cancer or ongoing therapies (e.g. operation and medical reports, imaging findings).
Procedure
The reconstruction of the breast after breast cancer can be carried out with implants or with the autologous tissue. Also suitable for use are oncoplastic and microsurgical methods, as well as flap plastic surgery.
Breast reconstruction with implants
Silicone implants have been used reliably and with good outcomes for decades not only for breast augmentation but also for reconstruction of the female breast. In more recent years, in addition to further developments of breast implants, techniques have been developed to further reduce the risks and complications of breast implants. In particular, the development of capsular fibrosis due to the shrinkage of the scar tissue around the implant as well as the palpability and visibility of the implant edges or folds (“rippling”) could be reduced by the development of special cell-free tissue implants (acellular dermal matrix, ADM) and mesh. Injection of autologous fatty tissue can be used as a complement to breast reconstruction with a silicone implant and contribute to a more natural aesthetic result. After a mastectomy with removal of the skin envelope, a tissue expander is usually implanted first to stretch the breast skin. In a second step, the definitive breast implant can then be inserted under the stretched skin and, if necessary, under the breast muscle. The ideal situation for breast reconstruction with a silicone implant is after breast cancer treatment where the breast skin and nipple have been preserved. In this case, the reconstruction with an adequately sized breast implant can even be immediately followed by the removal of the mammary gland (subcutaneous mastectomy), which means that a further operation can be avoided.
Breast reconstruction with autologous tissue
The advantage of breast reconstruction with autologous tissue (e.g. from the abdomen) is the durability and naturalness of the result. In contrast to a breast reconstruction with a silicone implant, the breast made with the patient’s own tissue behaves like normal breast tissue in the long term. This has the advantage that the symmetry of the reconstructed and healthy opposite breast is thus preserved even during the ageing process. In contrast, a breast implant does not age in the same way as the breast tissue of the healthy opposite side, which can lead to an asymmetry of the breast shape over the years. In this case, additional surgery may be required to restore the symmetry of the breast. The development of a scarred capsule around the implant (capsular fibrosis) or an implant defect (rupture) can also make further surgery necessary after a breast reconstruction with a silicone implant. If the breast skin over an implant is thin, the palpability or even visibility of the breast implant under the skin cannot always be avoided and may increase over the years due to the ageing process. Such late effects can be avoided by augmenting the breast with the patient’s own tissue.
Lipofilling for breast reconstruction
For the reconstruction of the breast with autologous tissue, especially after the partial removal of breast tissue in a breast-conserving treatment, fatty tissue can be obtained from other parts of the body using the technique of liposuction. With this, after appropriate cleaning and preparation of the fat cells, the breast can be filled and the shape and symmetry of the breast restored. Breast reconstruction can be carried out in one or more steps.
Oncoplastic surgery
Partial loss of breast tissue in rather large breasts can be compensated for by redistributing the breast tissue, according to the technique of breast reduction. In these cases, for reasons of symmetry, a breast reduction of the reciprocally healthy breast is usually advisable. If, on the other hand, a reduction of the breast is not desired, defects can also be filled with a tissue transfer from the surrounding area (local flap). The choice of procedure depends on the individual anatomy, whereby fat deposits in problem areas such as the flanks or upper abdomen can be used as donor areas for flap reconstruction. In analogy to the microsurgical breast reconstruction described below, local flaps are predominantly used today for partial breast defects. The underlying muscles are preserved during their removal by microsurgically exposing the flap vessels while sparing the muscles (perforator flaps). In the breast region, these include the Lateral Intercostal Artery Perforator (LICAP) flap and the Thoracodorsal Artery Perforator (TDAP) flap.
Microsurgical autologous tissue reconstruction
In these procedures, a combination of mainly skin and fatty tissue with the supplying blood vessels and sometimes also skin nerves is taken from another part of the body (free flap) and transplanted to the breast, where the vessels of the free flap are then connected to vessels of the same calibre in the breast region (recipient vessels). A surgical microscope is usually used to suture the vessel ends, which are only a few millimetres in diameter, which is why this technique is also called microsurgical reconstruction. The great advantage of microsurgical breast reconstruction is the removal of tissue from problem areas such as the lower abdomen, the inner thighs or the buttocks. Thus, on the one hand, sufficient tissue volume can be gained for the reconstruction of one breast or even both breasts and, at the same time, the body contour at the donor site can be improved (e.g. abdominoplasty, buttock lift, thigh lift). Before the introduction of microsurgical techniques, these tissues could only be relocated using the underlying muscles, which ensured the blood supply to the skin and fat tissue above. Today, muscles are spared by the microsurgical harvest, thus avoiding impairment of muscle function. Because the vessels perforating the muscle are exposed microsurgically, these flaps are also commonly referred to as perforator flaps.
Deep Inferior Epigastric Perforator (DIEP) flap
The so-called DIEP flap is the most commonly used microsurgical flap for breast reconstruction. It consists of skin and fatty tissue from the lower abdomen, which in many women is available in sufficient quantities to form a breast. With the DIEP flap method, the donor defect on the lower abdomen can be closed at the same time after removal of the flap, as with an abdominoplasty, which is an aesthetic advantage for many patients. The scar on the lower abdomen is similar to that after an abdominoplasty and can be easily covered even in swimwear.
In addition to the classic DIEP flap of the lower abdomen, other perforator flaps can be used in a similar way depending on the problem areas of the respective patient. These include the Superior Gluteal Artery Perforator (SGAP) flap and the Inferior Gluteal Artery Perforator (IGAP) flap from the upper and lower buttock region as well as the Transverse Myocutaneus Gracilis (TMG) flap, the Profunda Artery Perforator (PAP) flap from the inner thigh and the Fasciocutaneous Infragluteal (FCI) flap from the buttock crease.
Nipple reconstruction
The nipple and areola (nipple-areola complex) are important visual elements of the breast. Their reconstruction after a mastectomy is therefore an important part of restoring a symmetrical breast. The nipple is usually shaped by local tissue plasty (flap). Less frequently, if the nipple of the healthy breast is large, a partial grafting (“nipple sharing”) can be performed. The areola can be reconstructed either by a skin graft or by tattooing. In the latter case, the reconstructed nipple can also be tattooed to achieve a uniform skin colour. Optionally, the nipple of the other breast can be aligned by tattooing for better symmetry. For reasons of symmetry, nipple reconstruction is usually waited until at least 6 months after breast reconstruction, as the shape of the breast can still change significantly after reconstruction during this period.
Surgery of the opposite healthy breast
Sometimes, after a breast reconstruction, there is a desire for an equalising correction of the healthy opposite breast, for example because it is larger than the reconstructed breast or has a sagging shape due to age. In these cases, a breast reduction or breast lift can create better symmetry.
what are the risks of breast reconstruction?
Plastic surgeons working in breast centres have special experience and routine in reconstructing the breast with different techniques following breast cancer operations. When indicated and performed correctly, serious complications such as infections, wound healing disorders or circulatory disorders of the tissue (e.g. loss of the nipple or flap) are rare. In individual cases, however, they may require longer follow-up treatment or renewed surgery. For this reason, every woman should be informed about all risks and possible complications during a personal consultation before undergoing breast reconstruction.
Mild complications that usually heal without consequences include haematoma, seroma and swelling. Severe haematomas may require surgical removal. After breast cancer removal, there are often sensory disturbances of the breast skin and nipple, if these have been preserved, and often cannot be corrected by reconstruction of the breast.
General risks of breast reconstruction are:
- Haematoma (bruising), bleeding and swelling.
- Seroma (accumulation of wound secretions)
- Wound healing disorder or infection
- Implant perforation and removal
- Suture dehiscence (sutures coming apart)
- Injury to nerves or vessels
- Numbness (temporary or permanent) in the surgical area
- Circulatory disturbance of the breast skin or nipple
- Loss of tissue (e.g. in microsurgical flap plastic surgery)
- Scars
- Slight asymmetry
Overall, breast reconstruction in the hands of an experienced plastic surgeon is a safe procedure with few complications and high patient satisfaction. You, as a patient, can help to minimise certain risks by following the behaviour we recommend before and after the operation.
hoW to prepare for the surgery?
Our aim is to make the operation itself as well as the time before and after it as pleasant as possible for you. You can support us and yourself by following a few rules of conduct.
For example, it is advisable for smokers to stop smoking 2 weeks before and after the operation, as smoking can impair wound healing. Certain medicines that increase the risk of bleeding, such as aspirin, non-steroidal anti-inflammatory drugs and some vitamin preparations and homeopathic remedies should also be discontinued 2 weeks before the operation. You will receive precise instructions on this from us before the operation.
In individual cases, an ultrasound examination (sonography), X-ray examination (mammography) or magnetic resonance imaging (MRI) of the breast is recommended before breast reconstruction, which are usually carried out as part of breast cancer diagnosis and aftercare. Breast reconstruction does not increase the risk of developing cancer in the new breast. After reconstruction with a silicone implant, examination of the reconstructed breast with mammography may be limited, so in this case other imaging examinations, such as ultrasound and MRI, are used to monitor the breast. After reconstruction with autologous tissue, imaging examinations of the reconstructed breast are possible using all techniques.
Breast reconstructions are usually performed under general anaesthesia as part of an inpatient treatment of several days in hospital, where PD Dr. med. O Scheufler will operate on you. Exceptions are minor procedures with a short operating time, such as lipofilling or reconstruction of the nipple and areola, which are usually performed on an outpatient basis under local anaesthesia in the practice. In this case, you should ensure that you can be collected after the operation.
day of sugery
Breast reconstruction is usually performed as an inpatient procedure in a private hospital (Salem-Spital Bern or Bethesda-Spital Basel). As a rule, the patient is admitted to hospital on the morning of the day of the operation. In individual cases, admission can also take place the day before. You will discuss this with your attending doctor.
During the operation you will be given various medications to make you feel comfortable. As a rule, breast reconstruction is performed under general anaesthesia. For your safety, your blood pressure, pulse and blood oxygen level will be monitored during the operation.
At the end of the operation, a special breast bandage or support bra will be applied and you will be taken to the recovery room where you will continue to be monitored until you are fully awake. Depending on the type of reconstruction, you may be able to get up on the same day (e.g. after breast reconstruction with implants). After breast reconstructions with microsurgical tissue transfer (free flap breast reconstruction), you will be observed on the intermediate or intensive care unit during the first night in order to closely check the blood circulation of the grafted tissue. If the blood circulation is not conspicuous, you will usually be transferred to the ward the following day and monitored there for several days during your stay. On the day after the operation, you will usually be able to stand up regularly and walk for a few minutes to minimise the risk of thrombosis. The pain after breast reconstruction is usually not severe and can be compared to a severe muscle ache. It can usually be treated well with a combination of painkillers, which you can continue to take during the first few days and, if necessary, at home as needed. Your surgeon will instruct you in detail about what to do after the operation, as this varies depending on the specific surgical procedure performed.
after surgery
It is important to know that the recovery time after each operation varies individually and depending on the reconstructive procedure. In the first few days after breast reconstruction, you should take it easy on yourself physically and not raise your arms above shoulder height or lift heavily. You will usually need to sleep on your back for a few days. Only take the painkillers prescribed and do not take any medicines containing aspirin or other anticoagulants. Wear the special bra fitted to you and, if necessary, other corsetry continuously for a total of 6-8 weeks and follow our recommendations. You should avoid physically strenuous and sporting activities for a few weeks.
During the first 2-5 days after the operation, you may experience a feeling of tension and slight soreness in the breast region. The skin of the breast and possibly other areas of skin where tissue has been removed may feel numb or hypersensitive. Numbness is usually temporary and improves over time. However, it can take weeks to months, or even longer in some cases, for the feeling to return to normal. After breast cancer removal, there is often a permanent loss of sensation in the affected breast. Slight swelling and bruising in the area of the breast and possibly at tissue removal sites, e.g. on the abdomen, usually disappear within 2-3 weeks. As a rule, you will be on your feet one to two days after the operation and can resume most of your daily activities after 2-3 weeks. The bandages and any wound drains will be removed in the first few days after the operation, after which you can shower normally again. However, you should avoid full baths and excessive heat (e.g. sauna) for several weeks until all swelling has subsided. Most skin sutures dissolve by themselves and do not need to be removed. Non-dissolvable sutures are removed after one week. You can often return to work as early as 2-3 weeks after breast reconstruction, depending on the activities required in your profession.
As further steps, we recommend starting intensive skin and scar care with moisturising skin ointments and light massage after the acute healing has been completed. In individual cases, special aftercare with silicone gel or silicone patches for 2-3 months may be advisable. The fresh scars should not be exposed to UV radiation for at least 6 months to prevent increased pigmentation.
After the operation, you will be examined at regular intervals at the AARE KLINIK by Dr. Scheufler, your attending physician, who will assess your individual healing progress until the final surgical result is achieved.
outcome
After the operation, the breast may still be swollen for some time and it may take a few weeks for it to take on its normal shape. The healing process is gradual and it takes several months before the final result of the operation can be assessed. The scars on the breast may be reddened or appear darker pigmented for several months, but they fade with time and are then usually hardly visible. Usually, scars can be easily concealed, even in cut-out dresses.
Breast reconstruction restores the body image and creates a better symmetry that resembles a natural breast, which offers both visual and functional advantages. It promotes a sense of well-being and can support a positive outlook on the future and a zest for life during the difficult period following breast cancer treatment. Restoring bodily integrity helps regain self-confidence and makes it easier to wear certain clothes.
The results of breast reconstruction are usually permanent. However, gravity and the ageing process continuously affect every woman’s breast, gradually changing its shape and size over the years. This also affects a breast reconstructed with the body’s own tissue in the same way, so that the symmetry is also maintained in the long term. After breast reconstruction with implants, visual changes in the reconstructed or reciprocal breast may occur due to the ageing of the material or encapsulation of the implant and subsequent further operations may be necessary. However, even with implants, good aesthetic results and a natural breast shape can be achieved in most cases in the long term.
Costs of breast reconstruction
Breast reconstruction is a medically indicated operation and not a cosmetic surgery. The reconstruction of the breast after breast cancer is therefore covered by the health insurance funds, regardless of the method chosen. This also includes the costs for reconstruction of the nipple and areola. In addition, the health insurance companies now recognise the costs of breast reduction or breast lift operations as a compulsory service. The costs of such an operation are therefore also covered by the health insurance funds. In individual cases, in which there is no clear compulsory benefit from the health insurance funds, the assumption of costs can be checked with a cost approval application before an operation.
Appointment for a breast-reconstruction with Dr. Scheufler in Bern
Before any breast surgery you should have a comprehensive consultation and additional examination. Only in this way can you be sure whether the type of surgery will lead to the result you expect. In addition, your consultation will give you a good impression of our experience in the field of breast surgery. Feel free to ask for before and after photos to get an idea of what the results look like.
PD Dr. Oliver Scheufler, board certified plastic, reconstructive and aesthetic surgeon and author of this website, is pleased to be at your service for a personal consultation. Besides his main occupation at the AARE KLINIK, Dr. Scheufler is also scientifically active and lectures at the University of Basel. He also was a visiting professor at Duke University (USA). Please do not hesitate to contact him if you wish a professional consultation!