1. Implant Reconstruction
(with or without skin expansion, mesh or matrix)
Implant reconstruction is a well-established method for immediate breast reconstruction, where a silicone gel-filled implant is used to replace the removed breast tissue, possibly in combination with a mesh or acellular matrix. The surgical effort is lower than with other methods, and no additional scars are usually created. However, symmetry with the healthy breast is often only achievable after correcting the healthy breast. Many patients report differences in perceived temperature and weight between the reconstructed and healthy breasts.
If the breast skin cannot be preserved during the breast cancer surgery, a tissue expander can be used to gradually stretch the skin (and, if necessary, the muscles). The expander is filled with fluid over several weeks, and once the desired volume is reached, it is replaced with the final implant in a second surgery. The so-called expander prosthesis remains in place after expansion and is not replaced by an implant.
One complication of implant reconstruction is capsular fibrosis, which can cause the reconstructed breast to become hardened and painful, leading to necessary corrective surgeries. This often negates the initial time advantage of implant reconstruction. Patients should also be informed of the very rare risk of breast implant-associated anaplastic large cell lymphoma, which may influence implant choice.
2. Autologous Tissue Reconstruction with Flap Techniques
Autologous tissue reconstruction involves transplanting skin and fat tissue from the abdomen, buttocks, or thighs to the breast and microsurgically connecting fine blood vessels. These blood vessels are located before or during surgery using CT or ultrasound. The delicate blood vessels, approximately 1–3 mm in size, are microsurgically connected to blood vessels in the breast area, and the tissue is shaped into the breast. These microsurgical techniques require specialized training and years of experience. We are certified by the German Society for Plastic, Reconstructive, and Aesthetic Surgery (DGPRÄC) as "Breast Surgeons specializing in microsurgical breast reconstructions."
The advantage of autologous tissue methods is that they recreate a natural breast, even larger volumes. The body's own tissue ensures that the breast feels natural and warm to the touch. Another benefit is that the reconstructed breast changes similarly to the healthy breast in response to weight changes and aging. The reconstructed breast is permanent.
Scar progression around the areola
The following flap techniques are commonly used:
DIEP / SIEA (skin-fat tissue from the abdomen), TRAM (with muscle)
FCI / I-GAP / S-GAP (skin-fat tissue from the buttocks)
TMG / PAP (skin-fat tissue and muscle from the thigh)
The procedures differ based on the tissue extraction site, which can lead to different postoperative results, such as scarring.
DIEP (Deep Inferior Epigastric Artery Perforator Flap)
SIEA (Superficial Inferior Epigastric Artery Flap)
In the DIEP flap technique, a skin and fat tissue strip is taken from the lower abdomen. This requires sufficient skin and fat tissue and intact blood vessels in the area. Unlike the TRAM method, the abdominal muscles and the fascia remain intact, reducing the risk of abdominal wall weakness or hernias.
The incision is usually closed in a way that provides a "tummy tuck" effect, which most patients appreciate. The remaining scar runs horizontally at the lower abdomen level and around the newly created navel.
Illustration of DIEP flap surgery and residual scarring
For patients with sufficient skin-fat tissue in the abdomen, both breasts can be reconstructed if necessary, depending on the desired breast size.
TRAM (Transverse Rectus Abdominis Muscle Flap)
In the TRAM method, the rectus abdominis muscle is also harvested, in contrast to the DIEP. Despite reinforcing the abdominal wall with a synthetic mesh, there is a higher risk of abdominal wall weakness or hernias, so this method is not recommended as a standard approach anymore.
FCI (FascioCutaneous Infragluteal Free Flap)
I-GAP / S-GAP (Inferior / Superior Gluteal Artery Perforator Flap)
These methods are typically used when there is insufficient skin-fat tissue in the abdomen or if the abdomen has extensive scarring. The tissue for reconstruction is taken from the lower or upper buttocks (FCI, I-GAP, or S-GAP). In the preferred FCI flap technique, the scar is placed in the buttock crease.
The skin and fat tissue required for reconstruction is harvested from the buttocks using these surgical techniques: from the lower buttock region in FCI and I-GAP, and from the upper buttock region in the now very rarely used S-GAP. The gluteus maximus muscle is preserved; once again, the blood vessels are traced through the muscle. In the FCI flap technique, which we prefer, a scar remains in the gluteal fold. The nerves responsible for the sensitivity of the back of the thigh must be carefully dissected from the blood vessels to avoid long-term numbness in that area. Hip flexion on the affected side is limited for several weeks.
Scheme FCI / I-GAP (lower) und S-GAP (upper) flap reconstructions with postoperative scar locations
TMG (Transverse Musculocutaneous Gracilis Flap),
PAP (Profunda Artery Perforator Flap)
With these methods, a crescent-shaped skin-fat flap is harvested from the inner thigh, and in the case of the TMG flap, a narrow muscle (the gracilis muscle) is also included, whose loss is functionally insignificant. This procedure requires a surplus of tissue in the thigh area that corresponds to the size of the breast to be reconstructed. Closing the resulting defect often has the added benefit of a thigh lift. Typically, a discreet scar remains in the groin, inner thigh, or gluteal fold. For bilateral breast reconstruction, symmetrical flap harvesting from both thighs is possible in two separate operations.
In TMG procedures, partial preservation or expansion of the breast skin is necessary.
Diagram of TMG flap reconstruction
3. Autologous fat grafting
In autologous fat grafting, breast volume is restored by injecting the patient’s own fat tissue. This fat is first harvested via liposuction from suitable areas of the body. According to current literature, there is no clear correlation between the donor site and the graft survival rate of the transplanted fat. Therefore, the donor site can be chosen based on the desired postoperative body contour.
I use water-assisted liposuction to harvest the fat tissue, a method that yields a particularly high proportion of viable fat cells and thus allows for a high graft survival rate. Before transplantation, the fat is specially processed. To ensure the highest possible graft take, the fat must be injected in limited portions, and a portion of the transplanted fat and the fluid it contains is naturally broken down shortly after the procedure. Therefore, depending on the size of the breast to be reconstructed, multiple procedures are usually necessary.
An essential requirement is preserved breast skin with a sufficiently thick subcutaneous fat layer. In rare cases, expanding the skin-fat envelope — which leads to compression of the fat layer under the skin where the fat is to be transplanted — may be part of a suitable treatment concept for successful breast reconstruction.
The method of external tissue expansion using a negative-pressure device (BRAVA) before and after fat grafting, which was used to stretch the skin envelope, is currently not available. Transplanting fat into the breast muscle often leads to unnatural breast movement during muscle contraction.
Overall, fat grafting alone is only the best method for breast reconstruction in very rare cases. However, it is very well suited for fine-tuning the shape of the breast following other reconstruction procedures.
Before performing liposuction — for example, from the abdomen, inner thighs, or buttocks — for breast reconstruction after breast cancer, the surgeon is obligated to inform the patient about the subsequently limited options for autologous tissue reconstruction using the aforementioned flap techniques.
Due to the current state of research, there are certain limitations to fat grafting following breast-conserving therapy, in cases of genetic predisposition to breast cancer, and with certain precancerous breast conditions.
Since fat grafting is still not part of the standard care covered by health insurance, an application for cost coverage must be submitted along with a justification of the treatment concept.
4. M. latissimus dorsi
(large back muscle, possibly with implant)
In this reconstruction method, the latissimus dorsi muscle is partially or completely transferred from the back to the chest wall, sometimes along with a skin flap, and shaped into a breast. Without an implant, only the reconstruction of a small breast is possible; usually, an additional implant is required. The functional loss of the back muscle is only partially compensated. A potential drawback is the unnatural movement of the reconstructed breast, despite the nerve that activates the muscle being severed. This method is generally used as an alternative or secondary option.
Nipple Reconstruction
To complete the reconstructed breast, most patients wish to restore the nipple-areola complex. This is typically done through small local flaps, where skin and subcutaneous tissue are shaped into a nipple-like structure. Sometimes, a part of the healthy nipple on the opposite breast can be shared and moved to the reconstructed breast, although this can reduce the sensation in the healthy nipple. Another option is to reconstruct the nipple using a skin graft.
The nipple-areola complex can also be recreated through professional pigmentation, either after the surgical restoration of a plastic nipple or as a one-step 3D pigmentation procedure.
Choosing the Surgical Method and Surgeon
The choice of surgical method should be made collaboratively after thorough information and consultation with the patient. The procedure depends on the patient's physical situation, her desires, and the circumstances following the removal of the breast tissue. For optimal breast reconstruction, there must be good collaboration between the treating breast surgeons, oncologists, gynecologists, and the plastic surgeon. The plastic surgeon should be part of a certified breast center and be skilled in all methods of breast reconstruction, including technically demanding autologous tissue reconstructions with microsurgical vascular connections. The patient should only proceed with the method that best suits her after being fully informed about the expected outcomes, risks, possible complications, and aftercare.
Treatment Costs
The costs of consultations, surgery, and follow-up care for breast reconstruction after breast cancer are generally covered by health insurance. Exceptions may include fat transplantation, symmetry surgeries of the opposite breast, and areola pigmentation, in which cases pre-treatment approval for coverage is necessary, and we are happy to assist patients with this.
Surgical Preparation and Aftercare
Before the surgery, a detailed consultation takes place. For certain surgeries, such as autologous tissue reconstruction with microsurgical vascular connection, smoking cessation is required for a successful operation. Surgery is typically planned at least six months after radiation therapy. Certain medications must be reviewed before and after surgery. In rare cases, autologous blood donation is indicated. Further preoperative tests may be necessary.
The hospital stay depends on the surgical method, ranging from a few days to up to eight days. Patients are given pain relief and blood-thinning medications as needed, and any wound drains are removed after a few days.
It is usually recommended to wear compression garments for four to six weeks, which are fitted before surgery. Full arm use is generally possible after four to six weeks, depending on the surgery. Work absence can vary from a few days to six weeks. Physiotherapy may be necessary after surgery.
Surgical scars will fade over several months, and exposure to UV light should be avoided. Secondary surgeries, such as adjustments to the opposite breast or nipple-areola complex reconstruction, are typically planned before the initial breast-reconstruction and are usually performed at least three months after the breast
