Of the 20,000 women who have a mastectomy each year in France, after breast cancer or as part of a preventive ablation for patients with
genetic predisposition, only 25% choose to start breast reconstruction,
according to a study by the High Authority for Health (HAS).
And for good reason, with the multiplicity of techniques – and the different advantages and disadvantages of each of them – it is sometimes difficult to find your way around. Breast prostheses, lipofilling, flap… The choice of technique depends on the wishes of the patient, her morphology, medical factors (treatments received before or after) and risk factors (smoking, obesity, diabetes).
Increasingly secure breast prostheses
Patients can choose prosthetic reconstruction, one of the most popular techniques. It consists of inserting one or two implants, in gel or silicone, in front of or behind the pectoral muscle. “This technique has the advantage of not adding scars, since we reuse that of the mastectomy”, explains Dr. Benjamin Sarfati, plastic surgeon in Paris and founder
of the Women’s Surgery Center. On the other hand, specifies the specialist, the implants have a limited lifespan and must be changed every ten to twenty years depending on the model.
“This is the technique that worries patients the most, because it is a foreign body that can be rejected. We may also have to change them if they tear. But current prostheses are filled with gel physiological serum; if they rupture, there is no mortal danger for the patients, it is considered that it is safe ”, tries to reassure Dr. Delphine Hequet, gynecologist in oncology at Institut Curie and specialist in breast reconstruction.
For women who would like to benefit from breast reconstruction to increase the size of their breasts, expanders must first be placed. It is a deflated temporary prosthesis, which we will gradually fill with physiological serum over the weeks, to stretch the skin and increase breast volume. Once the desired size is reached, a second surgery is necessary to remove the temporary prosthesis (s) and put on the permanent prostheses.
Autografts for a more natural result
For those whom the presence of a foreign body can worry about, several techniques known as “autologous” exist. This is the case of that of “free flaps”, which consists in removing the skin and fat (with the vessels which vascularize them) from the abdomen (what is called the Diep), from the internal face. thigh (PAP) or buttocks, and “reconnect” them behind the breast or in the auxiliary hollow. “This is the technique which has the most aesthetically satisfactory results, the result is very natural”, continues Dr Isabelle Sarfati, plastic surgeon specializing in breast surgery at Breast Institute. “It’s a kind of transplant, so it lives with the patients. Unlike prostheses, if patients lose weight, they will also lose breasts, ”adds Dr Delphine Hequet.
However, this technique, which requires 4 to 6 hours of operation, causes several scars: that of the area taken and that of breast reconstruction, leading to more risk of infections. “The graft may not take, there may be necrosis, leading to reoperation,” warns the gynecologist. She adds that since good vascularization is one of the keys to success, the intervention is impossible in diabetic, smoking or obese patients. But this is not the only criterion: “You need a sufficient excess of fat to be able to perform the sample, so it is not possible in thin women,” warns Dr. Isabelle Sarfati.
Patients can also choose reconstruction with a “pedicle flap”. This technique, which resembles the free flap, is practiced mainly with a tissue of the back, it is what is called “the latissimus dorsi”. The nuance, and not the least, is that the collected tissue remains irrigated on its original vessel. “We transfer the excess from the back to the thorax, leaving the vessels attached to the back and rotating them under the arm”, decrypts Isabelle Sarfati, who specifies that this technique, although not recommended for athletic patients, is possible in almost all the women.
For those who do not want a foreign body or scar, there is lipofilling: a removal of fat by liposuction in the buttocks, thighs, stomach or saddlebags, which is reinjected into the breasts. While this is the most attractive technique, since it does not cause any scars and no foreign bodies, it nevertheless requires several sessions, depending on the number of reconstructed breasts and the desired volume. “It’s quite paradoxical: for it to work, you need patients who have enough fat reserves but little breast”, indicates Isabelle Sarfati. “But there is an immediate loss of at least half of the fat injected, that is to say it dies immediately,” warns Dr. Delphine Hequet.
Find the right compromise
What patients sometimes ignore is that all of these techniques can be combined. Lipofilling, for example, is used more in a second stage of breast reconstruction, in addition to a prosthesis, to “resculpt the breast, adjust the symmetry or hide the edges of the prosthesis”, explains Isabelle Sarfati. For women who have recourse to a flap, whatever the type, “we can add a small prosthesis if the part taken is not sufficient”, adds Dr Delphine Hequet. “We put all these ingredients in a shaker and we try to find the best compromise,” adds Dr Isabelle Sarfati.
The three doctors are categorical, “it is a decision shared between the surgeon and the patient”: “You have to know what the patient wants and what is possible”, estimates Dr Benjamin Sarfati. “Some are ready to have several scars but want a more natural result, others prefer it to be less natural, but without any new scars,” he continues. While remembering that surgeons do not necessarily master all the techniques and that gathering several opinions is essential. Before concluding: “We must not forget that breast reconstruction remains an option, it is not compulsory. “