After breast cancer, breast reconstruction is progressing

ThoseAfter cancer –

“Our dream is to recreate a woman’s breast in the laboratory”

A majority of women opt for prostheses after a mastectomy. Yves Harder, director of the Reconstructive Surgery Department at CHUV, discusses other options.

BotTalk

• Each year, around 6,500 women in Switzerland report breast cancer.
• The CHUV performs approximately 200 breast reconstructions annually using various techniques.
• Immediate mastectomy with reconstruction is often offered to patients.
• Breast reconstruction is covered in Switzerland after a cancer diagnosis.

Which patients are affected by breast reconstruction?

Around 30% of women affected by breast cancer will not be able to keep their breast, and will undergo a total mastectomy. Today, in broad terms, this involves removing the breast gland, as well as the nipple and lymph nodes if necessary, and keeping the skin pocket.

This is why reconstruction is proposed immediately, at the same time as the mastectomy, to fill this pocket. The operation is the same for women who are not sick, but who have a risk of being sick in the future for genetic reasons, and who undergo a preventive mastectomy.

Isn’t it strange to lose your breast and have it reconstructed immediately, without transition?

This is what specialists have long thought: that the woman had to remain without breasts for some time, in order to mourn. In fact, recent studies show that immediate reconstruction, even more so if it is carried out with the patient’s own tissues, is very appreciated and helps a lot to accept herself.

Several methods exist: that with prostheses, and that known as the “flap”. Can you explain the principles to us?

At the CHUV, some 60% of patients choose prostheses, and 40% opt for the flap, that is to say vascularized fatty tissue, taken where it is in excess, particularly most often at the stomach level.

But each solution must be personalized according to each patient, and the two can be complementary. The prosthesis is attractive because it is installed in a single operation, but you should know that over time it can migrate, harden or crack. So it is likely that it will need to be replaced. This is not anecdotal: after five to seven years, the failure rate can reach 60%.

Can we really have confidence in these prostheses, after the scandal that took place in the 2010s?

I hope this is all over. A single, highly recognized American company produces the silicone used to make prosthetics around the world. And there have been a lot of improvements in the field.

Some patients have their prostheses that slip when they raise their arm. Weird, right?

This can especially happen with prostheses that have a smooth surface, because they do not adhere to adjacent tissues. It’s a little uncomfortable, of course, but the rougher prostheses can also move and present a minimal risk of developing associated lymphoma, so they are gradually being withdrawn from the market or under observation.

What are the advantages of reconstruction with your own tissues?

It is more natural and more durable: even if the primary operation is more complex and longer, and often requires small touch-ups, the reconstruction will last a lifetime.

How does it work?

I take tissue from the stomach, thighs or buttocks, and I transpose them after connecting the vessels. These breasts are warm, more sensitive and softer than a prosthesis, and if you get bigger, they get bigger too. Depending on the amount removed, the scar on the stomach will be quite long – like a large cesarean section. But you will also have a flatter stomach.

What about the nipple?

The original nipple is usually preserved, if the disease allows it. Otherwise, we usually reconstruct it with skin from the reconstructed breast and then tattoo it.

So the patient loses all her sensitivity in the chest?

This is a question that is being increasingly taken into account. Already, at the time of the mastectomy, we can try to preserve the nerves which go to the nipple. Afterwards, at the time of flap reconstruction, we can also connect the nerves of these tissues at the level of the stomach, to those along a rib. It won’t be as sensitive as before, but it’s a marked improvement. And new innovations from the United States will also make it possible to further improve this.

How big are the scars?

It depends on the initial size of the breast to be reconstructed and also on the need to lift the breast or not. If this is the case, there will always be a scar around the areola, otherwise we manage to limit the scars between the areola and the fold under the breast.

Do women sometimes have to pay out of pocket?

In Switzerland, we are privileged, because as soon as the diagnosis of cancer is made, the reconstruction is fully covered, whatever the option chosen and whatever the

number of interventions to finalize a reconstruction. After a few years, if the prosthesis needs to be changed or if the woman changes her mind, this is also reimbursed. The same goes for reducing or increasing the size of the second breast, in order to harmonize the chest in the event that there has only been one mastectomy.

Is progress to be expected?

We are now able to reconstruct more natural and sensitive breasts. But our dream is to recreate a woman’s breast in the laboratory, from her own cells. We are already able to start the process, but success will not happen right away, because we must then be able to graft this breast onto the patient and connect all the vessels. Let’s be honest: this will still take some time.

Is breast reconstruction mandatory?

No way! Little by little, also in Switzerland, we are starting to talk about “flat thorax” and its aesthetics. The trend is important in English-speaking countries, and here more and more women are thinking about living with a flat chest. This option must be offered as one of the possibilities after mastectomy. It is up to us, doctors, to adapt to the wishes of patients.